Frimley Health and Care System Sustainability and ......ambition to transform the ‘social care...

0 0

Frimley Health and Care System

Sustainability and Transformation Plan

21 Oct 2016 Submission

1

Co

nte

nts

1

Contents

Section One

Section Two

Section Three

Section Four

Section Five

Section Six

Introduction & plan on a page…………………

Section Seven

2

Section Nine

Seven initiatives: our focus for 2016-18…….

Five transformational enablers…………….…

Leadership & governance………………...……

Appendices

Finance…………………………………………….

Mental health and learning disabilities…...…

Communications and engagement….….……

………………….…………….…….………………

4

18

23

22

24

30

31

2

Statement All of the partners involved in the STP are committed to putting residents first. In practice this translates to people receiving/having access to seamless holistic services that meet their need at the earliest possible opportunity – right service, right time and right place. Through focussing on the individual, as opposed to structure, there is an increased focus on prevention and pro-active care rather than reactive treatment. The partners are taking collective responsibility for simplifying the system and making it easier for people to understand and navigate it.

The first two years of our five year STP will be delivered through seven system initiatives that integrate commissioning decisions and provider delivery. These are set out in detail in this submission.

Workforce The priorities described in the STP will be underpinned by developing the right workforce with the right skills, knowledge and understanding to transform our services and pathways. Consequently one of our initiatives is dedicated to workforce development and the remaining six initiatives having to create a workforce plan. The STP Local Workforce Action Board is utilising Health Education England, universities and other education providers to drive the plans forward.

Summary of progress since June

Established all of the workstreams to provide a coherent plan that clearly demonstrates the impact of each initiative with defined deliverables and benefits to the population.

• Increased the breadth of ownership and leadership of our STP through broad engagement

• Engagement and workshops with providers and commissioners to support alignment of primary and community care strategy and workforce resilience.

• Established the Local Workforce Action Board to respond to the workforce issues arising from each initiative.

• Further aligned the Local Digital Roadmap to the STP Priorities. • Given a stronger voice to mental health and ensured that all seven

key initiatives build in the requirements of the Mental Health Five Year Forward Plan.

• Developed an STP wide Communications and Engagement Strategy. • Developed and updated the financial plan to reflect guidance and

feedback from the September submission.

In order to meet this challenge one of our five priorities is

therefore:

1. Making a substantial change to improve wellbeing,

increase prevention, self-care and early detection

Introduction to the Frimley Health & Care STP Aim: To serve and work in partnership with the Frimley footprint population of 750,000 people, through the local system leaders working collaboratively to provide an integrated health and social care system fit for the future.

The Frimley Health & Care STP will provide benefits to the communities and individuals will: • Be supported to remain as healthy, active, independent and happy as they can be. • Receive better coordination of heath & social care system - a ‘no wrong door’ approach. • Know who to contact if they need help and be offered care and support in their home that is well organised, only having to tell their story once. • Work in partnership with their care and support team to plan and manage their own care, leading to improved health, confidence and wellbeing. • Find it easy to navigate the urgent and emergency care system and most of their care will be easily accessed close to where they live. • Have confidence that the treatment they are offered is evidence based and results in high quality outcomes wherever they live - reduced variation through

delivery of evidence based care and support. • Increase their skills and confidence to take responsibility for their own health and care in their communities. • Benefit from a greater use of technology that gives them easier access to information and services. • As taxpayers, be assured that care is provided in an efficient and integrated way.

Sectio

n O

ne

3

Priority 1: Making a substantial step

change to improve wellbeing,

increase prevention, self-care and

early detection.

Priority 2: Action to improve long term

condition outcomes including greater

self management & proactive

management across all providers for

people with single long term conditions

Priority 3: Frailty Management:

Proactive management of frail patients

with multiple complex physical & mental

health long term conditions, reducing

crises and prolonged hospital stays.

Priority 4: Redesigning urgent and

emergency care, including

integrated working and primary care

models providing timely care in the

most appropriate place

Priority 5: Reducing variation and

health inequalities across pathways

to improve outcomes and maximise

value for citizens across the

population, supported by evidence.

Many of our residents have the skills, confidence and support to take responsibility for their own health and wellbeing. We can

do more to assist them in this and are committed to developing integrated decision making hubs with phased implementation across our

area by 2018. Integrated hubs provide a foundation for a new model of general practice, provided at scale. This includes development of

GP federations to improve resilience and capacity and provides the space for our GPs to serve their residents in a hub that has the support of a

fit for purpose support workforce. Delivering services direct to residents in locations that suit them, at times that suit them, supports our

ambition to transform the ‘social care support market’. Through a personalised yet systematic approach to delivery of health and social care

we have the possibility of reducing clinical variation. Change will be delivered through advances in technology and we will implement a

shared care record.

Ou

r p

rio

riti

es

fo

r th

e n

ex

t 5

ye

ars

An underpinning programme of transformational enablers includes:

A. Becoming a system with a collective focus on the whole population. B. Developing communities and social networks so that people have the skills and

confidence to take responsibility for their own health and care in their communities. C. Developing the workforce across our system so that it is able to delivery our

new models of care. D. Using technology to enable patients and our workforce to improve wellbeing, care, outcomes and efficiency. E. Developing the Estate.

Plan on a page: The Frimley Health & Care STP In

tro

du

cti

on

Se

ve

n in

itia

tive

s o

n w

hic

h w

e w

ill fo

cu

s i

n 2

01

6/1

7-1

7/1

8

Su

mm

ary

Fin

an

cia

l A

naly

sis

Initiative 1: Ensure people have the skills,

confidence and support to take

responsibility for their own health and

wellbeing.

Initiative 4: Design a support workforce that

is fit for purpose across the system

Initiative 2: Develop integrated decision

making hubs to provide single points of

access to services such as rapid response

and reablement, phased by 2018.

Initiative 6: Reduce clinical variation to

improve outcomes and maximise value for

individuals across the population.

Initiative 3: Lay foundations for a new model

of general practice provided at scale,

including development of GP federations to

improve resilience and capacity.

Initiative 5: Transform the social care

support market including a comprehensive

capacity and demand analysis and market

management.

Initiative 7: Implement a shared care record

that is accessible to professionals across the

STP footprint.

Sectio

n O

ne

• The Frimley system will spend

c£1.4bn on health and social care in

2016/17.

• Although there are modest increases

in funding over the period to 2020/21,

demand will far outstrip these

increases if we do nothing.

• We have assumed health providers

can make efficiency savings of 3% pa,

and demand can be mitigated by 1%

pa. This is in line with historic levels of

achievement and existing efficiency

plans following the acquisition of

Heatherwood & Wexham Park hospital

in 2014. Including broader efficiencies

from Social Care will deliver about

£176m by 2020/21.

• If a further £28m can be saved across

our main priority areas, this coupled

with an allocation of £47m from the

national Sustainability and

Transformation Fund (STF) will bring

the system into balance by the end of

the period Do Nothing Solutions Do Something

£m £m £m

Commissioner Surplus / (Deficit) (100) 89 (11)

Provider Surplus / (Deficit) (87) 80 (7)

Footprint NHS Surplus / (Deficit) (187) 169 (18)

Indicative STF Allocation 2020/21 - - 47

Surplus /(Deficit) after STF Allocation (187) 169 29

Social Care Surplus / (Deficit) (49) 27 (22)

Total Surplus / (Deficit) (236) 197 7

STP 2020/21 Summary

4

Digital transformation initiatives such as patient portal, patient facing technology, whole system intelligence and shared care record

Health and wellbeing strategies

Vanguard pilot in North East Hampshire and Farnham

Underpinning all of the other initiatives within the STP

Blood pressure detection matches best performer in comparator CCGs

An additional 18,135 residents are identified through the national diabetes prevention programme

Reduction in growth rates of diabetes incidence

Through offers to quit support an additional 463 smokers quit per year

Reduction in smoking related surgical site infections by 147 per yr

Alcohol care teams setup across Frimley footprint

Alcohol related deaths decreased by 20%

Reduction in number of people with BMI over 30 by 2680

Frimley footprint physical inactivity decreases to below 20%

Increase in the availability of patient facing and patient portal technology

Successful roll out of effective Vanguard intervention programmes

• This project will focus on people within the Frimley footprint which covers 5 CCG areas and serves a population of 750,000.

• Digital enablement to encourage self-care and prevention

• Although other areas of prevention may interface with this

project they will not be considered in scope.

• Develop a range of digital, telephone and face to face support for people with high risk lifestyle behaviours or mental health characteristics

• Introduce a digital support package that encourages behaviour change linking with the One You programme

• Supporting a healthy NHS workforce enhancing the Commissioning for Quality and Innovation initiatives to deliver sickness absence reductions and reduced agency requirements

• Year 1 and Year 2 priorities will be tobacco cessation in elective care, early cardiac detection, diabetes and physical inactivity utilising digital technology via a patient portal and nudge techniques as part of these programmes

• Learn from the Vanguard self-care initiatives, for example, healthy living pharmacies and safe haven model for mental health and replicating effective interventions across the STP footprint

• Support self-care through identification and use of digital platforms such as patient portal, patient facing technology and shared care record across the STP footprint to develop comprehensive care and support planning

• Work in collaboration with the Fire Service to enable joined up front line service delivery

Milestones Scope and exclusions Overall Objectives

Key risks/ Issues

1. Programme implemented across STP to detect higher than normal blood pressure within primary care and the community

2. Roll out of national diabetes prevention programme

3. Offers of quit support for smokers undertaking elective procedures

4. Alcohol Care Teams in hospital sites and brief intervention in health settings building on work of the alcohol liaison nurses

5. Training of staff to improve the understanding of lifestyle risks, maximising every contact counts

6. Obesity reduction programme setup throughout footprint

7. Develop and implement digital programmes to support healthy lifestyles e.g. to encourage inactive residents to increase physical activity

8. Roll out successes of Vanguard interventions

Interdependencies

Deliverables

Outcome measures

Just over £7.6 million net saving over the 5 years

Reduction in smoking and alcohol consumption

Earlier intervention for diabetes and hypertension

Reduced sickness, improving the economy and society

Improved cohesion between NHS, Fire Service and Local Authorities

Health and wellbeing improved within Frimley footprint

Contact with hard to reach groups and increasing reach through digital platform

Areas with the poorest outcomes will be prioritised in the roll out of all initiatives to ensure we address health inequalities

Digital ecosystem setup that will encourage sharing of care records and ownership for their own wellbeing

Benefits

Milestones Start Date End Date

Development of a project to increase referrals to the National Diabetes Prevention Programme

Feb 16 Oct 17

Project documentation approved 30 Sep 16 17 Oct 16

Model the financial impact Oct 16 Oct 16 Agree definition and terms of reference for steering group

17 Oct 16 17 Oct 16

Submit the STP 21 Oct 16

National Diabetes Prevention Programme Pilot Schemes start

28 Oct 16

Develop and agree a detailed framework

Oct 16 Nov 16

Setup and agree project teams for deliverables

Oct 16 Nov 16

Develop and roll out programme to reduce the number of people smoking within footprint

Oct 16 Dec 17

A fully implemented primary care/community programme for early detection of high blood pressure

Dec 16 May 17

Develop and implement targeted health promotion to reduce alcohol consumption

Mar 17 Oct 17

Project to promote an increase in physical activity

Mar 17 Oct 17

Evaluate Vanguard self-care interventions and roll out if evidence supports

Feb 17 Feb 18

Develop, implement and evaluate a digital platform to support self-care

Feb 19 Jan 20

Risks Mitigation

Lack of agreement on design principles / framework

Ensure maximum engagement ahead of required agreement

date

Senior management support Continual updates to System Leadership Reference Group

Public engagement and involvement

Co-production elements where possible and ensuring

continual communication through a variety of conduits

Public health funding risk Strong return of investment

justifies funding

Ensure people have the skills and support to take responsibility for their own health and wellbeing. Lead Director: Lise Llewellyn, Director of Public Health; Project Manager, Ben Rowlands

I1 Se

ction

Two

5

Health and Wellbeing Boards

Frimley System Leadership Reference Group

Prevention and Self Care Group

Programme

• Agree a detailed design / implementation framework aligned to current project

• Agree project team • Approve project brief

Take responsibility for their own health roadmap - high level integrated view Q4 2016/17 Q1 2017/18 Q2 2017/18 Q3 2016/17

Ke

y go

vern

ance

me

eti

ngs

Q4 2017/18 Q3 2017/18

4th Oct 27th Oct 10th Nov 24th Nov 29th Nov

17th Oct Held monthly tbc

30th Nov 15th Feb

16th Nov 29th Mar

8th Dec 2nd Mar

14th Dec 27th Feb 7th June 27th Sep 13th Dec

9th Mar 8th Dec

8th Dec 16th Feb

Initiation and Visioning Designing and Planning Creation and Delivery

• Agree a detailed design / implementation framework • Agree project team • Approve project brief

• Identify cohorts for high impact interventions • Continual monitoring and evaluation to work

group

Early detection of high blood pressure

• Engage Prevention and Self-Care work group

• Model financial impact

• Select pilot areas for high impact interventions • Train staff in identified pilot area • Continual monitoring and evaluation to work

group

Increase referrals for diabetes

• Review project already underway • Engage Prevention and Self-Care

work group

• Agree pathway and practical steps for service delivery • Undertake review of current offerings in footprint • Agree project team • Approve project brief

• Tender for provider • Communicate and train staff • Continual monitoring and evaluation to work

group

Reduce number of people smoking



• Agree a detailed design / implementation framework • Agree project team • Review work undertaken by alcohol liaison nurses • Approve project brief

• Select pilot areas for high impact interventions • Communicate and train staff • Continual monitoring and evaluation to work

group

Reduce consumption of alcohol



• Agree a detailed design / implementation framework • Review digital technology opportunities • Agree project team • Approve project brief


group

Increase physical activity

• Agree a detailed design / implementation framework • Review digital technology opportunities • Agree project team • Approve project brief


group

Implement digital platform



• Undertake review of Vanguard project • Agree pathway and practical steps for service delivery • Agree project team • Approve project brief

• Communicate and train staff • Roll out successful initiatives • Continual monitoring and evaluation to work

group

Evaluate Vanguard Self-Care project





• Develop the logic model based on development roadmap • Agree specific outcome measures across the system • Establish performance and outcomes baselines • Agree benefits realisation and evaluation strategy

• Establish measurement mechanisms • Develop a system wide digital dashboard • Refine the strategy and logic model

Metrics and Evaluation

• Develop a draft logic model • Apply Vanguard evaluation strategy • Agree system wide high level

metrics

STP Submission 21.10.16 Project delivery

Sectio

n Tw

o

I1

6

Interdependencies

Outcome Measures


Key risks/ Issues

Deliverables

Benefits

Milestones

Start

Date

End

Date

System wide workshop on core elements Aug 16 Sep 16

Modelling the financial impact Oct 16 Oct 16

Review the draft STP project documentation Sep 16 Oct 16

System leaders on ‘TCSL’ leadership course Oct 16 Jan 17

Submit the STP 21 Oct 16

Agree delivery and evaluation framework Oct 16 Nov 16

Develop logic model and evaluation strategy Oct 16 Nov 16

Convene a steering group aligned with ‘TCSL’ Oct 16 Nov 16

Map the current state of delivery Dec 16 Jan 17

Agree phased implementation plan Jan 17 Feb 17

Approve local planning and scheduling Feb 17 Mar 17

Implement quick wins in fast followers Mar 17 Sep 17

Refine the framework through rapid learning Mar 17 Sep 17

Develop a system wide digital dashboard Mar 17 Sep 17

Deploy refined framework at scale and pace Sep 17 Mar 18

Risks Mitigation

Lack of agreement on design principles / framework

Ensure maximum engagement ahead of required agreement

date

Complex dependences between programmes of work

Programme governance and robust communications plan

Decision making needs to be coordinated across multiple

statutory bodies

Robust critical path that takes into account decision making points and clear schedule of

delegation

Develop integrated care decision making hubs to provide single points of access to services such as rapid response and reablement, phased implementation by 2018 Lead Director : Fiona Slevin-Brown, Director of Strategy, East Berkshire CCGs; Project Manager, Haider Al-Shamary

Sectio

n Tw

o

I2

• System wide population based identification and proactive management of individuals with frailty

• Care Model Design: Develop a system wide model, based on NHSE Frameworks, for multidisciplinary teams to deliver community based care

• Digital Cohort Identification: Utilise whole system intelligence, Right Care, and predictive modelling, to identify and proactively manage cohorts with frailty

• Rapid Local Delivery: Build on local success and accelerate delivery at pace and scale across the system, with General Practice at the core

• Digital Enablers: Use a Shared Care Record, real time analytics, digital care services and multi-media sign posting

• Wider integration: Between health, social care and our community partners

• Mental Health Parity of Esteem: Join up physical and mental health care for high-need groups, such as people with severe mental illness and older people with dementia

• Prevention and Self Care: Collaborate with local authority, voluntary, and community partners, promoting prevention, early intervention, and community support

• Shared Processes: Shared risk processes, assessments, and a single shared care plan, targeting high impact interventions to enable proactive and preventative care

• Workforce Enablers: Introduce new roles and new ways of working e.g. care navigators, health coaches, clinical pharmacists, and integrated mental health leads

• Identify frail cohort of individuals in order to enable

proactive planning.

• Clinical and virtual hubs with co-located MDTs

• MDT coordination of complex care planning and frailty

• Targeted support for defined cohorts based on need

• Aligned crisis response, rehabilitation and reablement

• Rapid access to diagnostics and upstream diagnosis

• Social prescribing and asset based community support

• Aligned, integrated and simplified routes into UEC

• Streamlined primary, community and acute care interfaces

• Specialists and generalists working around the person

• Digital dashboard utilising whole system intelligence

• Flexible workforce able to work across the system

Other STP Initiatives and deliverables including Primary Care Transformation, Workforce, Unwarranted Variation, Social Care Support, Prevention and Self-Care

Local Digital Roadmap and associated digital ecosystem

Local Integrated Urgent and Emergency Care and NHS111 Redesign

This initiative is concerned with the collaborative design of a system wide integrated care model framework for local delivery and implementation. The evolving scope will need to be aligned to the development of other STP initiatives and deliverables as they evolve.

• Early access to proactive integrated services for individuals identified as frail

• Adoption of single trusted assessments and care planning • Use of a Shared Care Record accessible across all settings • Individuals will only have to tell their story once • Individuals supported by personal recovery guides and

navigators • Reduced crisis, impacting on emergency admissions, bed days

and admissions into care homes to improve quality of care • Enhanced supported discharge into community settings • Improved experience of individuals and equity of access for all • Helping people maintain independence and manage their own

health and care e.g. through expanded use of social prescribing • Optimising quality of life and increasing healthy lifespan • Social, emotional and psychological support in partnership

with the individual • Care homes integrated into the wider system

1. Incremental reduction in non elective attendance towards 30% for the patient cohort identified as frail and managed within integrated hubs

2. Increase in frail cohort being treated proactively in same day/next day services

3. Reduction in proportion of people identified as frail readmitted within 30 days.

4. 75% of patients identified as frail have a proactive plan in place led by the integrated hub.

5. 50% of those identified as most frail will have a crisis prevention plan in place

6. Patient and carer satisfaction regarding care coordination and telling their story only once.

7. Staff satisfaction with integrated team working specifically regarding risk sharing.

7

Integrated care decision making hubs Roadmap – high level integrated view Oct 16 – Mar 17 Mar 17 – Sep 17

Local Workforce Advisory Group

East Berkshire Governance Groups


Surrey Heath Governance Groups

NEH&F Governance Groups

First Draft Brief 03.10.16 STP Submission

Empowering Patients, Citizens and Communities

Local Authority Governance Groups

Communications Group

Oct 17 – Mar 18

Implementation

NHS Improvement Leadership Programme

Applying the six principles of effective engagement and participation throughout the programme:

Care and support is person-centred: personalised, coordinating and empowering

Focus on narrowing health inequalities

Voluntary, community, social enterprise and housing sectors are involved as key partners

Services are created in partnership with citizens and communities

Carers are identified, supported and involved

Volunteering and social action as key enablers, including healthy living pharmacies

Designing and Planning Implementing and Refining System Wide Rollout

• Agree a detailed design / implementation framework • Align to New Care Models implementation matrix • Map current state and agree implementation priorities • Align with other STP initiatives and deliverables • Develop local implementation schedules • Carry out digital frailty segmentation

• Develop the detailed financial and business model

• Identify mild, moderate and high frailty cohorts for interventions

• Build integrated care teams and hubs • Accelerate phased implementation

• Develop the logic model based on agreed framework • Agree specific outcome measures across the system • Establish performance and outcomes baselines • Agree a system wide evaluation strategy • Develop a system wide digital dashboard

• Establish population-based measurement mechanisms

• Refine the strategy and logic model

• Clinical and care leaders sharing expertise and supporting generalists / specialists to work together, sharing responsibility and accountability across MDT’s

• Establish a system wide steering group / learning network to feed into the Leadership Programme Cohort

• Utilise established local project delivery mechanisms to drive change in alignment with the care model framework

• Learning Network to spread existing and emerging best practice

• Joint workforce mapping and modelling • Agree shared workforce strategy and align with

regional networks • Training needs fully understood and planned

• Implement the new workforce model • Engage front line staff with training and

delivery • Capture and build on what works • Clearly defined roles and responsibilities

• Engage system leaders • Convene system wide workshop • Model financial impact • Agree core design framework • Align with NHSE Frameworks

Care Model Design

Metrics & Evaluation

• Develop draft logic model based on the NEH&F Vanguard model

• Apply the Vanguard strategy to evaluation

• Agree high levels metrics

• 8 local leaders embarking on ‘Transformational Change through System Leadership’ (TCSL) programme

Leadership, Governance and Local Delivery

Workforce Redesign

• Identifying new roles / training needs

• Connecting with LWAB and LETB for support

Local Digital Roadmap

A digital ecosystem that delivers key enablers such as a Shared Care Record, Patient Portal, Technology Enabled Care Services, and system wide Business Intelligence

Sectio

n Tw

o

Ke

y go

vern

ance

me

eti

ngs

I2

8

Deliverables


Key risks/ Issues

Interdependencies

Outcome measures

Benefits

Lay the foundations for a new model of General Practice provided at scale. Lead Director: Nicola Airey, Director of Planning, Surrey Heath CCG; Project Manager, Gazelle Robertson

Sectio

n Tw

o

I3

March ‘19 delivery of FYFV for General Practice across whole STP

8am-8pm Mon – Fri GP services including access for MH pts

Weekend GP services including access for MH patients

Improved working across primary, community & secondary care

Early intervention for LTC and complex patients

General practice working at scale through federations

Patient portal supported by LDR

Wider primary care workforce eg. Health navigators

System wide recruitment, retention strategy

Consultations using technology eg. Video, emails, telephone

Real time analytics tools in collaboration with LDR

Project Workstreams:

-Integrated care decision making hubs; -prevention & self care; -Social care; -Shared care record;

-Unwarranted variation; -Support workforce; -Mental Health

Enabling Workstreams:

-LWAB; -Technology; -Engagement - Estate

Milestones

Start

Date

End

Date Engagement exercise to:

-develop system wide views on GP transformation

-agree current good practice to spread across the system

-agree how to work better together and identify potential wide STP activities

Aug 16 Sept ‘16

Financial Modelling Sep ‘16 Oct ‘16

STP Submission Oct 16

Project Brief sign off

Sep ‘16 Oct ‘16

Establish an overarching workstream steering group

Oct 16 Nov 16

Project Implementation Nov 16 Mar ‘19

Evaluation process Mar ‘19 Mar ‘20

Risks Mitigation

Lack of engagement from general practice across the system

System wide ownership of STP priorities, engagement plan and commitment to achieve change

Insufficient resource to undertake associated workstream tasks

a fully staffed PMO driving and supporting the programme with leadership & input from across the system

General Practice workforce not fit for purpose to achieve change

-Workforce subgroup and link into wider workforce planning.

-Future proofed business and career models

-Retention strategies eg flexible working

Complexity of managing interdependencies across workstreams

PMO leads & system leads working closely together to ensure the alignment of priorities

• To deliver a sustainable model of general practice including a clinical, business and career model that delivers improved outcomes for our population

• To reduce variation in care and outcomes across the STP with a focus on: • Access • Mental Health • Prevention & early intervention • Patient experience • Urgent care pathway • Planned care referral thresholds • Long term conditions clinical outcomes • Use of technology to support access

• Generate pace and early delivery through: • Additional support to localities that need to strengthen

foundations • Enabling pacesetters to develop transformational

changes early • Identify fast followers to spread improvement at pace

• Clear articulation of system wide benefits of improvements in general practice

Working across the Frimley health & care system to achieve general practice transformation through

• care redesign & improved access;

• workforce, education & training;

• IT & infrastructure;

• workload;

• finance and engagement

Improved access from an increased number of appointments

Reduced variation in clinical outcomes and patient experience across the STP with specific ambitions to raise current levels of performance in Slough

Increased capacity to deal proactively with complex patients including those with LTC

Increased patient satisfaction and outcomes

Sustainable and fit for purpose workforce

Reduction in need to visit hospital services

Collaboration across the system

Increased general practice resilience

Economies of scale & greater system wide efficiencies

Reduced variation in % of patients satisfied with opening hours & overall average increase – from 18/19

% of patients rating their overall experience as good/very good, minimum 3% increase / 85% achieved – from Q4 17/18

Additional number of appts outside core hours – from Q1 18/19

Reduced variation in number of people with a LTC feeling supported to manage their care – 18/19

Development of metrics to identify improvements in early detection & intervention eg cancer diagnosis via emergency routes – 18/19

Examples of joint working across primary, community & secondary care – from Q1 18/19

Increased general practice workforce incl. new roles – from Q2 18/19

% use of digital platform to access general practice – from 18/19

% of patients redirected to self care from 18/19

9

General Practice at scale roadmap – high level integrated view

October November December September

Workload

Workforce, education & training

Ke

y go

vern

ance

me

eti

ngs

Engagement Event 27th

Workstream Steering Groups

Care redesign & improved access

Engagement Event -Sept ‘16

Project Brief– Oct’16

IT & Infrastructure

Finance & Investment

STP Submission – Oct ‘16

Workstream

steering group – Nov ‘16

Programme Implementation

–Nov ‘16

February January

Financial Modelling – Oct’16

Evaluation Process – March ‘19

Phase 1 - Oct ’16-March ’17

Care Model • Care re-design & Improved access • Workload

Phase 2 – April ’17 – Sept ’17 Phase 3 - Oct ’17 – March ’18 Phase 4 – April ’18 – March ’19

Career Model • Workforce, education & training

Business Model • IT & Infrastructure • Finance & ROI

Confirmed investment & phasing from NHSE

Project management structure in place

ROI finalised to feed into metrics

System wide initiatives identified & delivery process

Quick wins identified for STP spread

Workforce plan in place

Clinical model implementation: • Development / continuation of extended

access models • At scale working • 10 high impact actions • Support for struggling practices

Career model implementation • Recruitment & retention schemes • Develop new & supporting roles

Explore alternative technology solutions for accessing general practice Identify sign posting & self care apps

Develop premises strategy

Implementation of premises strategy

Contribution to overall financial sustainability of the Frimley Health & Care System Evaluation process


• Develop a draft logic model • Apply Vanguard evaluation strategy • Agree system wide high level metrics



Sectio

n Tw

o

I3

10

Key risks/ Issues

The detail of workforce changes will be defined by individual work streams and then picked up by this work stream for planning purposes.

The apprentices will be part of the core workforce undertaking support roles appropriate to their experience.

Delivery is based on access to the Frimley Health FHFT National Apprenticeship Scheme (NAS) infrastructure which has an anticipated levy of £1.7m pa to cover apprentice training.

Underpins the effective delivery of integrated care, and enables us to influence and change the social care support market.

Interdependencies

Number of apprenticeships established in each year

Improvement of % turnover of staff from current levels across all sectors

Number of staff rotating across sectors

Levels of skills attainment across the cohort

Reduction in agency spend across the cohort

Outcome measures

The Support Workforce covers a range of roles in health and social care including rehabilitation, reablement, domiciliary and support workers, care and healthcare assistants and residential care staff.

Staff are employed across the NHS, some local authorities and a wide range of private and third sector businesses.

It will not cover administrative support roles, nor those identified for professionally qualified practitioners.

Provide a workforce strategy that has identified the emerging roles, skills requirements and gaps in workforce provision across the system.

Deliver a training and development plan that supports staff to work across a variety of settings, and see career progression.

Establish a rotational apprenticeship scheme across health and social care employers that is increasing the workforce in line with demographic trends.

Provide career progression programme for bands 1-4, and an opportunity for those who wish to progress beyond this to a first registered position.

Establish a sustainable support workforce that provides an opportunity to develop new roles in the community.

Provide the underlying technology infrastructure to support cross organisational working aligned with the LDR

Deliverables


Offer people seamless integrated care delivery

Build greater confidence in individuals and their carers and families in the options for receiving care closer to home

Reduce the risk of delays and gaps in provision by providing a sustainable workforce with more consistent skills

A more flexible workforce able to pick up more skills and adapt to new roles in line with future challenges

Attract more staff into these sectors by providing good consistent training across the footprint

Benefits

We will work in partnership across the STP to recruit, retain and develop our support workforce to provide a joint workforce across organisations.

Initially we will complete a gap analysis on existing workforce, skills, vacancies and future requirements.

We will increase the pool of staff available in the footprint by: • Improving recruitment through joint working and agreed

terms and conditions across the system • Improving retention by offering positions across social care,

community and acute provision • Supporting our current staff with the opportunity to move

between health and social care, improving understanding of care delivery across the system

• Providing more development and progression opportunities within social care, community and acute care.

We are establishing a rotational apprentice scheme across social care, community and acute care which will begin in April 2017.

A pathway is being developed that will allow bands 1-4 to progress to pre-registration level, and have apprenticeships that will support band 4 staff to progress to band 5 registered nurses.

We will fully utilise the apprenticeship schemes to increase capacity, create new roles to support transformation and provide career progression for those looking for a professional role.

Risks Mitigation Lack of applicants Working alongside existing

hospital apprenticeship arrangements

Lack of placements Working alongside existing hospital apprenticeship arrangements

Delays in confirming new models for services

Cross team working developing work stream plans

An increase in staffing without role redesign will become a net increase in the spend on services.

The Support Workforce strategy will bring together work stream transformation plans to inform role redesign

Metrics of success are input focused and do not identify added value for people

Design of metrics during scheme implementation.

Milestones Start date End date

Develop STP Workforce

Strategy and associated

initiatives

13 Sept 31 Dec 16

Project agreement for

apprentice scheme 31 Oct 16

Bid for Innovation Fund grant 16 Sept 01 Dec 16

Develop recruitment product

for apprentices 1 Nov 31 Dec 16

Identify Training Manager for

apprenticeships

1 Nov 30 Nov 16

Identify training provider 30 Nov 31 Jan 17

Recruit first cohort of

apprentices 1 Jan 31 March 17

Design a support workforce that is fit for purpose across the system Lead Director: Nicola Airey, Director of Planning, Surrey Heath CCG; Project Manager, Nick Willmore

Sectio

n Tw

o

I4

11

Support workforce roadmap – high level integrated view November December January October

Berks Community

Community social care providers

Ke

y go

vern

ance

me

eti

ngs

Agree Project Brief

Care Home representatives

Frimley Health

Virgin

Support Workforce Strategy – analysis and planning

March February

STP Submission 21.10.16

System Leaders Group

Project steering group

Initiate quick wins

16

Workforce Strategy

• Analyse workforce data • Map gaps and vacancies across

consolidated local workforce • Identify potential new roles

• Develop plan to address demographic needs • Identify opportunities to rationalise service use • Work with stakeholders to identify new roles • Link roles to new NAS standards and SCIE roles.

• Agree approach to recruitment • Agree changes to service delivery • Define workforce plans to support training and

development

Resourcing Arrangements

• Quantify impact of demographic growth

• Identify potential to redefine roles to better utilise support workers

• Map growth against changes and quantify impact • Identify duplication of time delivering services • Review commissioning and clinical governance for

support services

• Develop common role descriptors • Define emerging roles • Revise contracts to reduce duplication • Develop integrated governance and contract monitoring

arrangements

Rotational Apprentices

• Link with HEE apprenticeship lead

• Agree NAS lead employer • Agree project governance

• Agree resourcing, • Identify training officer • Agree workforce contracts • Align provider arrangements for staff

• Recruit apprentices • Identify placements • Confirm standards being used





Sectio

n Tw

o

I4

12

Transform the ‘social care support’ market including a comprehensive capacity and demand analysis and market management Lead Director: Alan Sinclair, Interim Director of Adult Services, Slough Borough Council; Project Manager, Nick Willmore

Key risks/ Issues

• Care Home Support– Reduce acute admissions from care homes by 20%

• Complex needs review - Number of cases where support can be re-provided, target of 64 with total saving of £980,000

A market development plan that describes: •an analysis of demand for social care services •the modelling of alternative support options across the footprint •how local authorities are engaging with the care market •the role of non-institutional care in the community •how we are promoting innovation and stimulating new models of care

Care Home support that: •is reducing the number of urgent care admissions •ensures that people return to care homes from hospital in a timely manner •is making a difference to the experience of those in care homes •better supports people with dementia to remain in familiar surroundings. •has implemented the learning from the ECHC vanguards

A review of people with complex needs that •has ensured that they are receiving the best possible support •has increased their independence and control over the way they are supported •has supported innovation in the way that needs are met •has supported people to be closer to their natural support networks.

- Review of D2A initiatives to inform future developments

Deliverables

• There is a need to ensure that there is sustainable social care market in order to support the wider health and social care system. This is currently challenged by increases in demand and activity and the differential way in which care is purchased and delivered across the STP.

• The STP identifies the intention to make better use of home based care, to support innovation in the delivery of accommodation with support and to seek opportunities to make use of technologies that support independence, health and wellbeing in line with the LDR.

• To understand the local social care market in the STP and how best to ensure there is a good capacity and good quality of care at affordable prices

• Alternative care and support options are delivered including alternatives to care homes

• The needs of our most complex people – including people with mental health needs, learning disabilities and acquired brain injury - are understood and models of care are delivered that meet their needs in the least institutional environment

• People who live in care homes are supported well and only admitted to hospital when necessary and supported back home as quickly as possible, utilising digital technology where appropriate .

Scope and exclusions Overall Objectives

Outcome measures

Milestones Start date

End date

Market development plan 3 Oct 31 Dec 2016

Market development plan options sign off Dec 1Jan 2017

Market development options implemented

Jan 2017

Dec 2017

Care home support plan 14

Nov 1 April 2017

Complex needs review Dec April 2017

Complex needs options sign off April 2017

May 2017

Complex needs options implemented May 2017

Milestones

• The measures planned will focus on the social care market

provision.

• In order to maximise benefits the initial schemes will be

focussed on care homes or groups of individuals who make

the greatest demand on services in the community or in

hospital. Initially this can be measured through hospital returns

and levels of residential placements.

• The complex needs review will include people with a learning

disability, with mental health needs or with acquired brain

injuries.

• The five year strategy will need to develop local measures

designed to support people with mental health needs and

associated physical conditions.

• Support workforce – stability and capacity for home based care

• Prevention and self-care – to manage demand for services and reduce need for on-going support

• Social care record – to maximise impact of services

• Integrated Care Hubs – managing demand for services

• Enhanced use of Technology Enabled Care Services to support people to remain at home

• Partnership working to increase housing options

All services based on maintaining you in a familiar environment

Reduce the risk of extended admissions to hospital

Greater choice and control over type and place of care

Increasing and retaining your independence

Benefits to local residents

Sectio

n Tw

o

I5

Interdependencies

13

Social care support market roadmap – high level integrated view November December January October

Berks Community

BFC

Ke

y go

vern

ance

me

eti

ngs

Surrey CC

Hants Vanguard

RBWM

Agree Project Brief Agree resourcing

Slough

Frimley Health

Virgin

March February

Sign off plans STP Submission 21.10.16

System Leaders Group

Project steering group (three weekly)

On-going Scheme Impact Evaluation

Market Strategy

September

• Agree key areas for transformation • Agree service intervention principles • Identify areas of greatest impact • Evaluate potential for change • Link to mental health strategy

• Consult with providers on principles / potential innovation • Map demographic needs against services • Assess unmet need based on existing demand • Map resources to identify investment needs • Link to MH Forward View and LD programmes • Identify digital solutions to link needs to market place

• Define key actions to transform the market • Quantify impacts expected from strategy implementation • Agree changes in services with providers • Evaluate impact of changes in social care on the system.

Care Home

Support

• Map current resources • Align support to areas • Identify resource gaps • Agree resources to be created

• Develop service specification • Develop governance

• Appoint staff team • Locate base • Define metrics for evaluation • Agree first phase of homes to be supported • Align with primary care support

Complex Needs Review

• Appoint project team to review complex needs support

• Agree scope and target group • Undertake desk top review • Develop plan for re-provision

• Undertake individual reviews • Develop alternative support plans • Develop transitions programme for service changes

• Agree providers for individuals • Draw up service plans for individuals • Support transitions between services.



• Develop logic model based on development roadmap • Agree specific outcome measures across the system • Establish performance and outcomes baselines • Agree benefits realisation and evaluation strategy


Sectio

n Tw

o

I5

• Agreeing intervention model • Define target group • Identify high demand services • Develop pathways to community services • Link to shared care record

14

XXX

• Integrated care

• Shared care record

• GP Transformation

• Mental Health

Interdependencies

Outcome measures

Deliverables


Key risks/ Issues

Reduced spend across each of the pathways totalling £37m, with recurrent savings in excess of £16m from Year 4

Consistent alternative referral pathways for agreed conditions from Dec 2016

Equitable health provision for our population

Evidence based interventions developed across primary & secondary care

Joint working across primary, community and secondary care

Reduced variation benchmarked against national and STP data

Improved outcomes for patients across physical and mental health

Benefits

Specific improvements and reduction in variation across five disease areas through:

-consistent pathway development across providers

-risk stratification and case management across providers

-establishment of community clinics

-standardised service specifications

Intensive data sets across each of the disease areas by CCG and across the STP

Joint working across primary, community and secondary care

Reduction in financial spend across five disease areas

Risks

Mitigation

Quality of data to determine variation

Right Care Approach commissioning for value packs and SLA with CSU to obtain, monitor and analyse data

Lack of engagement across primary and secondary care

sign up from across the system and relevant clinicians feeding into workstream -continued engagement, -agreed principles and specific actions jointly developed

Focus on disease areas does not reduce variation

Right Care Approach and deep dive into data packs to reaffirm priority areas and continued monitoring of data to assess impact

Working across the Frimley Health system, using the Right Care Approach to reduce variation in:

-Respiratory – Phase 1 (Oct 16)

-Musculoskeletal – Phase 1 (Oct16)

-Neurology – Phase 1 (Oct 16)

-Circulation – Phase 2 (Sept 17)

-Genito-Urinary – Phase 2 (Sept 17)

Reducing clinical variation to improve outcomes and maximise value for individuals across the population. Lead Director: Ros Hartley, Director of Strategy and Partnerships, NEHF CCG; Project Manager, Gazelle Robertson

Sectio

n Tw

o

I6

• To use the Right Care Approach to reduce variation across our System for the five disease areas initially identified through the programme:

-Respiratory: development of specialist clinics

-MSK: consistent pathways rolled out to general practice

-Neurology: community outreach clinics

-Circulation: hypertension & stroke pathway development

-GU: better end of life recognition and drug monitoring

• To establish an agreed process for identifying and reducing variation across further pathways within the system.

• To utilise the medical expertise across our system, and the wider NHS and Social Care community, to ensure care pathways are fit for future service provision with up to date technologies to improve patient care.

• To spread good practice across the STP area to reduce variation in quality and outcomes across the five disease areas

Continuity of care and clearer information about care choices through standardised pathways – Q4 16/17

The extent of reduction in variation across the CCGs in each of the selected disease areas over 5 years:

Phase 1: -Respiratory

( Oct 2016) -MSK

-Neurology

to show improvements from April ’17

Phase 2: -Circulation

(Sept 2017) -GU

to show improvements from April ’18

Financial savings achieved over the four year cycle

Milestones

Start

Date

End

Date Engagement exercise to reaffirm priority areas

Sep 16 Oct ‘16

Complete financial modelling exercise and identify savings and areas for investment

Aug 16 Oct 16

STP submission

21 Oct 16

Project brief sign off Oct 16 Oct 16

Workstream steering group set up and establishment of subgroups with detailed action plans to undertake and complete actions within each of the disease areas

Oct 16 Nov 16

Programme implementation Nov 16 Oct 17

Develop an evaluation process with measurable outcomes to ensure programme achieves its aims and delivers change

Oct 17

15

Reducing clinical variation roadmap – high level integrated view October November December September

MSK subgroup

Neurology subgroup

Ke

y go

vern

ance

me

eti

ngs

Engagement Event 4th

Workstream Steering Group

Circulation subGroup

Engagement Events

Financial Modelling

Respiratory

GU subgroup

Respitaroty subgroup

STP Submission

Finance subgroup

Evaluation Process

Programme Implementation

February January

Workstream steering grp setup

MSK

Neurology

Circulation

GU

Finance

Engagement

Set up subgroup – Nov 2016

Subgroup to focus on: -community respiratory service; -case management for high users of urgent services; -standard hospital discharge checklist; -specific guidelines / referral checklist to access secondary care; -spread the learning from WAM & Bracknell & Ascot across the STP: Implementation from Dec 2016


Subgroup to focus on: -consistent MSK pathway to be rolled out to all practices; -consistency of Tier 2 services starting with NEH&F. Implementation from Dec 2016


Subgroup to focus on: -East Berkshire Neurology programme and spreading the learning across the STP; -community outreach services; -reduction of admission rates. Implementation Dec 2016

Data deep dive into Stroke & Heart disease – May – June 2017

Phase 1: Respiratory, MSK, Neurology Implementation from Nov 2016

Phase 2: Circulation, GU Implementation from Sept 2017

Set up sub group – Sept 2017 to implement actions

Determine community part of pathways Set up hypertension & stroke pathway

Reduce A&E attendances related to heart disease

Establish pathways on diabetes control

Data deep dive : May – June 2017

Set up subgroup – Sept 2017 to implement actions

Establish better end of life recognition

Establish better drug monitoring

Explore at home dialysis Explore at home dialysis

Risk stratification across providers Primary care training for better management of patients

Complete financial modelling – October 2016

Review impact on savings – Nov 2018



Undertake workshop to confirm priority areas – October 2016

Develop communication & engagement plan including key stakeholders, methods of communication and engagement and timescales

Set up subgroups

20





Sectio

n Tw

o

I6

16

Outcome Measures

Interdependencies

1. Setup shared care record workstream aligned with LDR

2. Achieve system wide agreement on the design framework

3. East Berkshire Connected Care Programme Go-Live

4. Agree phased implementation plan based on local readiness

5. Coordinate detailed process mapping

6. Develop the clinical and care professional led design

7. Turn the design into a functional shared care record

8. Operationalise the validated shared care record in pilot sites

9. Roll out the phased implementation

10. Embed new processes and refine the shared care record

11. Embed a continuous improvement cycle

Deliverables


Key risks/ Issues

• Local area requirements to work across more than one interoperable solution

• Formation of one STP LDR

• LDR work-streams

• Other STP initiatives

The initial objective of this initiative is the collaborative development of a Shared Care Record with system wide agreement of clinical / care professional and citizen collaborative design, to achieve the following: 1. Integrated Care: Better informed decision-making

across all health and care settings by allowing information generated in one care setting to be seen and acted upon in another, irrespective of geographical or organisational boundaries

2. Self-Care and Prevention through a Patient Portal: Citizen access to self-care and support tools via digital ecosystem

3. Urgent and Emergency Care: Having access to timely and relevant information will support care professionals. This information will reduce duplication and support the triage process.

4. GP Transformation: Supports with a person having to tell their story only once

5. Unwarranted Variation: Optimising the use of medicines, especially where such information is not even available.

6. Infrastructure: Information will flow safely and securely across all health and care settings

Phase Milestone

Start End

Visioning Align the Shared Care Record and interoperable

programmes to the STP

Aug 16 Oct 16

Planning Agree principles of a unified system STP / LDR Sep 16 Nov 16

Model the financial impact of proposed scope Oct 16 Oct 16

Submit the next iteration of the STP Oct 16

Set up Shared Care Record work-stream aligned

with LDR

Nov 16 Nov 16

Achieve agreement on the design framework

(East Berkshire Connected Care Go-Live in

November)

Nov 16 Jan 16

Agree a phased implementation plan based

on readiness

Jan 17 Jan 17

Develop a detailed iterative planning schedule Jan 17 Mar 17

Design Coordinate detailed process mapping Jan 17 Mar 17

Develop the detailed design – this design will

evolve and refine as the shared care record is

implemented in order to continuously develop

the solution based on end user feedback

Jan 17 Mar 17

Build Turn design into a functional shared care record Mar 17 May 17

Deploy Operationalise shared care record in pilot sites May 17 Jun 17

Roll out phased implementation – phasing

will be based on three tiers; organisational

and local area readiness, as well as the types

of data being made available

June 17 TBC

Stabilise Embed new processes and refine June 17 TBC

Maintain Embed a continuous improvement cycle June 17 TBC

Risk Mitigation

On-going discussions regarding

alignment of interoperable

solutions across the system

Managed through the STP LDR

board

Suppliers not able / willing to

deliver requirements

Apply a robust development

and contract assurance

mechanism

The shared care record is concerned with the development of

the clinical and care user interface to present a consolidated

view of patient information. The project will be delivered

through a phased iterative approach, with the initial phase

focussed on gathering, agreeing and implementing the

requirements across the system from a clinical and care

professional perspective. The interface between these

requirements and the essential development of the technical

infrastructure will be a key dependency. Future iterations of the

project will include a patient portal and integrated care planning

as examples

Benefits

Increased satisfaction (tell story once, increased confidence, personalised care)

Efficiency (e.g. reduction in letters, phone calls & faxes, triage and analyses, reduced referrals assessments and tests)

Improved efficiency (e.g. admissions and re-admissions,

Quality and safety of care (eg patient wishes including EOL, better decision making from seeing medical and social history)

Increased staff satisfaction Improved safeguarding

Individuals engaged in their care- better management of health

Enhanced use of technology to support people to remain at home

• % of users who report time saved looking for information (75%)

• % reduction in duplicate tests due to information in shared record (40%)

• % staff who report shared record contributes to better clinical outcomes (75%)

• % of staff who report access to shared care record improved patient safety (70%)

• % of staff who report portal has saved time (regardless of task- e.g. could be admin staff or clinical) (80%)

• % of clinicians (across different settings/clinical specialities) who use portal routinely at point of care.

Implement a shared care record that is accessible to professionals across the STP. Lead Director: Jane Hogg, Integration and Transformation Director, Frimley Health; Project Lead, Sharon Boundy

Sectio

n Tw

o

I7

17

Shared care record roadmap – high level integrated view Sep-Dec 16 Apr-Jun 17 Jan-Mar 17

Shared Care Record Workstream


Frimley System LDR Board

Connected Care Board

Design


Continuous Improvement

& Development

Phased Delivery

• Agree design principles

• Extensive engagement across all organisations • Detailed clinical and care professional design • Detailed process mapping • Agreeing a phased implementation Plan

• Carry out comprehensive usability and clinical and care safety testing

• Enable the shared care record in pilot sites to refine its usability on the front line through continuous improvement and development

Delivery will be phased

according to three tiers of

readiness

East Berkshire Connected Care Go-Live Nov ‘16

STP Submission 21.10.16

Phased Delivery based on Area, Organisation and Data Provision


Area

Organisation Within each area, different organisations will be ready to deploy the

shared care record at different stages, due to various factors including digital maturity. This will further influence who goes live and when.

Delivery planning will be aligned to the readiness of each area. E Berkshire will be followed by alignment with NEH&F and Surrey Heath

Digital maturity will have a further impact within each organisation, limiting the data that can be extracted. Different departments and data

items will therefore be available at different stages of deployment

Data Provision

Agile feedback loop between design and delivery to enable a continuous cycle of improvement and development - informed by end users



STP aligned Digital Ecosystem

Empowering Patients, Citizens and Communities

Applying the six principles of effective engagement and participation throughout the programme:

Care and support is person-centred: personalised, coordinating and empowering

Focus on narrowing health inequalities

Voluntary, community, social enterprise and housing sectors are involved as key contributors

Services are created in partnership with individuals and communities

Carers are identified, supported and involved

Volunteering and social action are recognised as key enablers

Sectio

n Tw

o

I7 K

ey

gove

rnan

ce

me

eti

ngs

18

Purpose: Becoming a system with a collective focus on the whole

population we serve and support throughout their lives – not a system

based on sectors, organisations, services or parts of the population.

We are making good progress in becoming a system with

a collective focus addressing the whole population. This

has been recognised and welcomed by key stakeholders

including Health and Wellbeing Boards and Health Watch

We are working across physical, psychological and social

wellbeing

By taking this whole population approach we aim to

ensure we’re working for the benefit of the population and

individuals within it rather than on the organisations who

are fragmenting care and support by the current delivery

mechanisms

This is increasingly reflected in everything we do and is

reinforced by our technology enabler, where the

information is wrapped around the individual rather than

from an organisational perspective

We are focusing on those groups who are particularly

vulnerable within the population, for example those with

severe mental health conditions, learning disabilities or

acquired brain injuries, where we know services and their

impact needs to be significantly improved.

Population Focus Developing Communities

These two transformational enablers provide an ethos and approach across all of our work.

Purpose: Developing communities and social networks so that

people have the skills and confidence to take responsibility for their

own health and care in their communities.

• All our residents and patients live as part of one or several different

communities and we are increasing our understanding and

connections with these as we move to delivering our initiatives

across our localities

• The support that communities can provide for people and their

families is substantial in supporting people in crisis, preventative

support and helping people to maintain their independence

• Working with all employers in the system will support them in

promoting the health and well-being of their employees and

encouraging social responsibility within their communities

• There are a plethora of community, faith and voluntary organisations

across the Frimley footprint that are already supporting people and

with more co-ordination they could support people in a more

structured way

• There will be further opportunities for volunteers to actively

participate in the health & wellbeing of their community and we are

reviewing the social prescribing scheme already implemented in the

Vanguard.

• A priority focus will be supporting people to be more included in their

community and therefore reduce the impact of social isolation (at

least 12% of older people report being isolated which increases the

risk of illness)

• Social networks and friendships not only have an impact on reducing

risk of illness they also help people recover when they have become

ill

• Councils and CCGs are already funding and supporting community

and voluntary groups and the focus of this funding will be reviewed

• There is a need to increase support to carers who fulfil a vital

function and promote greater resilience and stability.

A B

Sectio

n Th

ree

Transformational Enablers

19

Purpose: Developing the workforce across our system so that it is able to support self care and health promotion and

deliver our new models of care, recognising that this transformation will be achieved through development and

retention rather than recruitment and be within today’s costs.

The Local Workforce Action Board (LWAB) has been formed and has an agenda to deliver a set of overarching priorities and

respond to the workforce priorities from each initiative:

Transformational Enabler: Workforce

Prevention

and self

management

• Developing prevention as a core capability of staff

• Supporting the workforce to be healthy

• Learn from the new roles supporting social prescribing in the Vanguard

Integrated

decision

making hubs

• Investing in new roles including care navigators, mental health leads, pharmacists and

extensivists.

• Leadership and team development programmes for MDTs

• Training in best practice integrated care including case finding and care planning

General

practice at

scale

• Increasing the number of GPs and develop roles to support them

• Develop skills in primary care through training and continuous professional development

• Implement new roles, such as mental health therapists and clinical pharmacists

• Provide career opportunities and planning, including shadowing and portfolio roles

Support

workforce

• Complete a gap analysis of existing workforce, skills, vacancies and future requirements

• Establish a rotational apprenticeship scheme across social care, community and acute

care

• Develop career pathways with level 2/3 qualifications leading to professionally based level

5 qualifications

Social care

support

Market.

• Maximise the scope of the existing market

• Training provider staff to support more complex individuals

• Ensuring staff have the skills to meet the changing expectations of the community

Clinical

variation.

• Training non-medical staff to manage conditions as part of implementing new pathways

• Developing skills in case management for high risk patients

• Supporting staff to work across organisations

Shared care

record.

• Ensuring the system has the change management capability and capacity to implement

well and make the cultural and process changes to drive through the benefits

• Support front-line staff to continue to shape design and implementation

• Delivering effective training to all staff as part of implementation

C Se

ction

Thre

e

Completing the analysis of the whole system’s

workforce to achieve collective understanding of hot

spots and priorities

Identify the gaps, duplicates and crucial elements to

deliver transformational change

Complete a comprehensive diagnostic of staff

satisfaction, recruitment, retention and vacancies

across the whole system

Designing and developing a system that provides

effective leadership, mentorship and support as we

move to a greater emphasis and development of our

lower band workforce

System workforce priorities: Seven key initiatives workforce priorities:

• 22% of GPs and community nurses are aged 55+ as

are 22% of social care workers in local authority and

private sector settings

• The number of GPs and community nurses/ 1000

population is lower in our system than the national

average and significantly lower in East Berkshire

• Turnover rates vary greatly by sector and profession,

with the highest turnover found in the independent

home care and care home sector (33% during 2015)

Example workforce hotspots:

20

Transformational Enabler: Technology - LDR and STP alignment

Local Digital Roadmaps

There are currently three LDR’s within the Frimley STP footprint which cross

multiple boarders. This introduces significant complexity when trying to

provide a consistent and coherent digital approach to support the STP

priorities. It is proposed that the Berkshire East LDR is dissolved and a

single Frimley LDR is established with North East Hampshire and Farnham

and Surrey Heath as partners so that it completely aligns with the STP

footprint.

This is a primary objective of the STP/LDR leadership and programme

teams, with a first meeting of the Frimley Digital Roadmap Board in

November. First steps for this Board will be to align interoperable solutions

with the Frimley STP footprint working across borders where possible.

In conjunction with the national objective around paper free at the point of

care and the associated capabilities, the Frimley LDR will have an

overarching vision to deliver three key objectives:

An information sharing mechanism for health and social care

professionals

A patient facing portal

Whole system intelligence/Population analytics for new models of care

As illustrated below, these are intrinsically linked and will support all the STP

priorities.

Alignment with STP

It is recognised that technology has a significant part to play to

deliver the whole system transformation agenda. The STP priorities

and initiatives are now driving the whole digital strategy. Digital

transformation threads through all the STP initiatives and significant

opportunities have already been identified that can stretch the digital

support offered. One example of this is an opportunity to provide

behaviour change through to technology to the STP workforce.

Learning from this can then be applied to a larger wellbeing agenda

for our patients/residents. Details of the workstreams that have been

established to support delivery of the universal capabilities and how

these have also been aligned with STP priorities and initiatives are

included as an appendix. This ensures that our workforce is

delivering multiple technology and transformation objectives.

Delivering technology that will support the STP

Several workstreams have been proposed and some have already

been initiated and more information on these are included as an

appendix. These workstreams will have clear deliverables,

mandates from Chief Executives, and accountability. These are

important principles as multi-organisational projects are complex and

historically have not delivered at the pace that is required to support

STP’s. There is a commitment from partners to work differently and

at scale. This will not only support the STP, but will ensure that the

universal capabilities progress, support paper free at point of care

and ensure resources are utilised more efficiently. provides an

example of how these workstreams are evolving.

Purpose: Using technology to enable individuals and our workforce to improve wellbeing, care, outcomes and efficiency.

Sectio

n Th

ree

D

21

Purpose: to deliver an efficient and fit for purpose estate infrastructure across the STP footprint that

supports delivery of the seven initiatives and new care models.

Priorities:

• Combining the One Public Estate work across the STP footprint to make optimal use of the estate and deliver co-location of services that improve integration of care and support and efficiency. Considering local options across the public sector for a shared approach to property maintenance and management.

• Securing a local agreement about the use of benefits from disposals and their support to develop our new care models

• Achieve a greater collective influence on NHS Property Services to prioritise the estate improvements required to deliver our STP – many of which are not fit for purpose.

• Address the immediate estate constraints in primary care to ensure it is fit for purpose. This will include:

• Refurbishing buildings where they don’t meet standards

• Investing in new accommodation that expands the range of services and delivers new care models

• Delivering co-location options

• Identify locations for and develop integrated care decision making hubs across all localities by the end of 2018

• Deliver significant capital investment and reconfiguration of acute estate to transform elective care at Heatherwood Hospital and the emergency and maternity departments at Wexham Park Hospital to improve productivity and the quality of care.

• Ensure administrative estate is consolidated to facilitate Carter recommendations.

Transformational Enabler: Developing the estate E Se

ction

Thre

e

22

Mental health and learning disabilities

Initiative Mental Health Deliverables

Prevention & Self

Care

Recovery focussed services: using evidence-based interventions to improve health and wellbeing and help people

secure employment. Developing perinatal and child and adolescent mental health services in line with national

guidance to reduce incidence of ongoing mental health problems. Tackling health inequalities through screening

and treatment, eg. smoking cessation support. Expanding the use of online interventions and use of technology to

increase access, choice and engagement in lifestyle change. Use of technology to keep people at home, eg. the

innovative test bed programme for Dementia patients. Rapid access to support preventing escalation into crisis and

avoidable hospital admission (including mental health liaison services and safe havens/crisis cafes).

GP

Transformation

Integration of mental health practitioners in extended primary care teams; including Clinician to clinician video

consultation , redesigned mental health practitioner roles, expanding talking therapies for long term condition use,

and developing integrated physical mental health and learning disabilities pathways within primary care .

Social Care

Support

Effective support to Care Homes including comprehensive training about dementia for leaders, training of staff and

in-reach services to minimise non-elective admissions. Integrated community services to support people in their

own homes, including effective support of carers.

Unwarranted

Variation

Scale learning and spreading good practice including integrated approaches (Surrey Heath and NEHF Vanguard)

and evidence–based interventions representing greatest value (Early Implementer site for Increasing Access to

Psychological Therapies). Reduce variation in delayed transfers of care, bed occupancy rates and numbers of out

of area placements.

Integrated Care

Decision Making

Hubs

Embed mental health practitioners in the integrated decision making hubs to ensure seamless interface between

primary care, secondary care and the acute system for people with mental illness. Share learning from integrated

physical and mental health approaches in Surrey Heath and NEHF Vanguard.

Support

Workforce

Enabling delivery of safe, sustainable services and achievement of targets to reduce use of agency staff.

Embedding psychologically informed approaches to assessment & interventions across the whole health & care

workforce. Training in ‘Making every Contact Count’ and support of Shared Decision Making. Development of new

roles to promote wider integration of peer mentors & wellbeing ambassadors. Recruitment & training to promote

digital competence, enabling delivery of online and technology enabled interventions.

Sectio

n Fo

ur

The Frimley Health and Care STP places a strong focus on supporting good mental health and physical health and will support the delivery of the Five Year Forward View for Mental Health and our local transforming care plans for people with learning disabilities. The delivery of the STP requires mental health and learning disabilities to be integrated throughout the plan and this has been embedded in each workstream. The following table describes this for each initiative.

23

Leadership & governance for delivery From successful planning to successful delivery

The Frimley system brings together a group of high performing and

ambitious providers, commissioners and systems. The leadership

and governance arrangements that we put in place to deliver our

Plan have been successful. We have reviewed these to ensure that

they are now focused on successful delivery and have added a new

Executive Delivery Group that will provide programme management

and support.

There has been some discussion and exploration across the

vanguard and Surrey Heath alliance to identify ways of moving

towards an Accountable Care Organisation governance structure

which may be suitable to roll out across the STP in future years.

Initial discussions have taken place at System Leaders Reference

Group about System Control Totals and agreement was reached

to operate in shadow form across the STP for 17/18. Principles

governing this are being developed for consideration. Where

possible learning will be considered from national and regional

examples where systems are ahead of ours.

Our governance structure

The bedrock of effective leadership and engagement across

our footprint is the 3 established system leadership

groups:

East Berkshire System Leadership Group

North East Hampshire and Farnham Vanguard

Leadership Group

Surrey Heath Alliance

The Frimley System-Wide Leadership Group brings

together all of the members from these three groups (50

people) to support collaborative leadership development

and cross-system support and relationship building.

The Frimley System Leadership Reference Group

This group, chaired by Sir Andrew Morris, works on behalf

of the three established system leadership groups to steer

and lead delivery of the STP plan. It brings together the

CCG Chief Officers and leadership representatives for the

public, local authorities and clinicians.

Frimley System Executive Delivery Group

Comprised of Executive Directors representing the localities

and sectors that form the STP. Provides programme

management and support to the workstreams and reports to

the Leadership Reference Group.

Initiative Delivery Groups

Will be established both from existing delivery groups within

the STP areas and newly formed as appropriate, reporting

into the Executive Delivery Group.

Wider stakeholders

Wider scale engagement has taken place with groups such

Healthwatch, PPI groups and voluntary sector

organisations. An Elected members and a Lay members

group has been established with the support of the Local

Authority as well as an advisory group for mental health.

Sectio

n Five

System Wide Leadership Group

East Berkshire System Leaders Group

Frimley System Leadership Reference

Group

NE Hampshire and Farnham Vanguard Leadership Group

Frimley System Executive Delivery

Group

Surrey Heath Alliance

Integrated hubs

GP transform

ation

Shared care

record

Social care

support

Support workforce

Clinical variation

Prevention

Local Authority elected members

Lay members

24

Where we are now

A whole system activity and financial model has been developed for all publically funded health and social care across our system. The model shows the size of the financial challenge for our system and the potential impact of introducing new models of care and efficiencies. This has been used to populate the national financial templates.

A ‘do nothing’ base case has been calculated showing the impact of demographic change, inflation and other growth factors including investments required to meet the priorities outlined in the Five Year Forward View such as delivering seven day a week services, improving mental health and enhancing general practice access.

The ‘do nothing’ base case split by sector is:

Frimley STP ‘do nothing’ gap 2020/21 NHS Commissioners £100m Local NHS Providers £87m Local Authorities £49m

Total £236m

In addition to being unaffordable, the implied demand would require an increase in acute bed capacity of about 10%.

Bridging the gap in 2020/21

Recognising that the system will need to make broader efficiencies a second scenario has been modelled taking the gap of £236m and reducing demand by 1% and delivering 3% health provider savings each year, plus social care efficiencies. This scenario incorporates the medium term efficiency assumptions arising from the acquisition of Heatherwood & Wexham Park Hospital by Frimley Park in 2014. It also assumes that Specialist Commissioners are able to deliver their planned savings.

If this can be achieved it would reduce the gap to £85m, which would need to be met by a combination of transformational savings and an additional allocation from the national Sustainability and Transformation Fund (STF).

Although the broader efficiencies are largely commensurate with previous levels of delivery the challenge in delivering a further £151m of savings (64% of the gap) mustn’t be underestimated. It will require applying Right Care principles to all our activities, and new ways of system-wide working to ensure overall costs are genuinely reduced, rather than just moved between organisations. Without our transformational interventions, these broader efficiencies will not be achieved.

Sectio

n Tw

o

24 Finance & efficiency – case for change Se

ction

Six

25

Organisational control totals

At the beginning of October NHS providers and CCGs were issued with ‘control totals’ for 2017/18 and 2018/19. These are effectively the surpluses they are required to achieve. The CCGs in the Frimley Health & Care STP are able to ‘drawdown’ from surpluses accumulated in previous years by c£1m pa, but for the next two years providers are required to make in-year surpluses of £24m. (For Frimley Health FT this is roughly 3.5% of turnover). We have included these requirements in our plans. For the last two years of the plan we have assumed lower provider surpluses of 1%.

Activity assumptions

We have modelled the impact of existing commissioner activity reduction plans and our system wide solutions on the underlying trajectory for acute hospital activity. The ‘do nothing’ position reflects impact of the underlying population growth in our area, coupled with the rising demand of an aging population. We believe our solutions will both mitigate the rate of growth (through for example improved self care) and increase hospital efficiency so more patients can be seen within the same resources (through better pathway management and greater use of technology). We are therefore not planning for a significant change in the total acute bed stock

Sectio

n Fo

ur

25 Finance & efficiency – modelling assumptions (1)

Social care assumptions

Our vision is for a financially sustainable health and social care system, therefore understanding the growing pressures on social care and the interrelationship with heath has been central to many of our solutions. For financial modelling we have taken a consistent approach across the three Unitary Authorities and two County Councils in our area, modelling adult social care, children's social care and public health costs. By 2020/21 we estimate a pressure on these services of c£22m (after taking account of solutions and precept changes). This is broadly matched by the remaining health surplus (having already delivered the assumed control total requirements

Capital investment plans

Significant capital investments are planned for Heatherwood Hospital (a full redevelopment to provide a state-of-the-art elective care centre) and Wexham Park Hospital (new emergency and maternity departments). These are all already provided for in Department of Health capital plans. CCGs are also bidding for capital funding to support primary care redesign, and as a system we are also asking for additional investment to develop our ‘digital ecosystem’.

Sectio

n Six

2017/18 2018/19 2019/20 2020/21 Total

£m £m £m £m £m

Approved schemes and primary care bids 71.5 57.6 21.5 12.5 163.1

Backlog maintenance 36.9 22.8 12.0 9.3 81.0

Sub Total 108.4 80.4 33.6 21.7 244.1

Total New Capital Expenditure Required To Implement Solutions 19.9 12.8 3.3 5.8 41.7

Total Capital Expenditure 128.3 93.2 36.8 27.5 285.8

of which is currently committed in DH plans 79.2 58.4 0.0 0.0 137.6

26

Specialist commissioning

Our detailed financial template incorporates expenditure estimates calculated by NHS England specialist commissioning teams. There is a key assumption that these costs can be contained with their published funding allocations. Although these rise by 16% between 2016/17 and 2020/21, in the underlying ‘do nothing’ position costs rise faster for specialist commissioning than for normal acute activity (by 34% compared to 17%) and therefore solutions which will save £30m are being identified by specialist commissioning colleagues.

For our STP modelling we have assumed that these solutions will deliver and will not have a detrimental impact on our local NHS providers (the majority of this activity is undertaken elsewhere in the country) and if there are definitional changes in what ‘counts’ as specialist commissioning, they will be fully matched by funding allocation changes

Commissioner funding allocations

Throughout our modelling we have used the allocations for the CCG, primary care and specialist sectors published in January 2016, and have adjusted for any subsequently agreed recurrent allocation changes.

Excluded items

It should be noted that costs and matching funding for the NE Hampshire and Farnham PACs Vanguard programme has not been included in 2017/18 (c£5m). Also excluded is the recently approved Talking Therapies expansion for Berkshire East.

Sectio

n Fo

ur

26 Finance & efficiency – modelling assumptions (2)

Primary care assumptions

The financial plan incorporates all primary care (GP) funding, irrespective of whether these budgets are fully delegated to CCG yet. Primary care allocations are due to rise by 16% by 2020/21 whereas core CCG allocations only increase by 12%. This reflects some of the commitments made in NHS England’s GP Five Year Forward View document to improve investments in primary care. In addition our solutions invest a further £8.5m in GP transformation over the period. Total primary care expenditure (excluding prescribing) is forecast to rise from £111m in 2016/17 to £136m, over 21%, a larger increase than either the acute or mental health sectors.

Funding support for Frimley acquisition

When Frimley Health FT acquired Heatherwood and Wexham Park Hospitals in 2014 a package of financial support was agreed between the Department of Health, NHS England and local commissioners. In terms of the STP submission our plan matches income to cost for the transaction money and integration so there is no net impact on the bottom line, and the deficit support is included in the overall Trust income assumption

Note: table based on original agreement, some re-phasing has occurred

Sectio

n Six

2017/18 2018/19 2019/20 2020/21

£m £m £m £m

Deficit Support (DH) 16.6 13.8

Public Dividiend Capital (DH) 11.7

Capital Expenditure Support (DH) 37.7 11.9

Transaction Support (DH) 4.4 4.3 2.7

Integration Support (CCG & NHSE) 1.7 1.5 1.2

Total 60.4 31.5 15.6 0.0

27

Financial impact of solutions

Each of the initiatives described in Section Two has been supported by a project accountant who has undertaken the financial evaluation of the costs and benefits. The outputs from the individual workstreams have also be reviewed to ensure savings are not double-counted.

Overall savings are forecast to exceed £65m over the next four years. As shown in the table below, we have chosen to group the majority of savings against five initiatives, with the remaining two (the support workforce and implementing a shared care record) as ‘enablers’ rather than undertaking a further somewhat artificial apportionment of savings across more categories. But these areas or no less important. In addition, many of the initiatives also underpin the continued delivery of provider Cost Improvement Programmes (CIPs) at c3% pa. For example the Support Workforce programme which aims to improve recruitment and retention and to develop a rotational apprentice scheme, aims to deliver a net benefit of £2.2m over the next four years, but there savings are contained within provider CIPs. Our costings include £500k for programme management to support implementation of the seven initiatives.

Stuff

The digital ecosystem

Our Local Digital Roadmap (LDR) describes our ambition to develop a digital ecosystem across health and social care, and further details are contained in the appendix. We have undertaken a comprehensive review of investment requirements across Frimley Health FT, Berkshire Healthcare FT, Primary Care and the local authorities in East Berkshire. Over the period to 2020/21 the system is already planning to invest £30m of capital and £8m of revenue on this agenda, however to make the Frimley Health and Care System a truly digitally enabled economy, there is a need to invest a further £33m of capital and revenue as shown below.

Sectio

n Fo

ur

27 Finance & efficiency – solutions

Mental Health investments The other main area of investment, in line with the Five Year Forward View, is mental health, with budgets forecast to increase by over £5m (in addition to normal baseline growth)

Sectio

n Six

Total Bid

Capital Revenue Estimated ROI

£k £k £k

Information sharing 7,209 5,911 14,751

Patient facing technology 4,458 7,259 18,115

Paper free at point of care 4,964 3,395 8,472

Total 16,631 16,565 41,338

2017/18 2018/19 2019/20 2020/21 Total

£m £m £m £m £m

Self Care & Prevention 1.1 1.1 1.2 1.4 4.8

Integrated Decision Making Hubs 0.7 2.3 3.9 5.5 12.4

General Practice transformation (1.6) 0.1 2.5 6.2 7.1

Right Care - Reduce Unwarranted Variation 4.3 6.3 11.8 14.1 36.5

Social Care Transformation 0.9 1.3 1.1 1.1 4.5

Total 5.4 11.2 20.5 28.4 65.4

2017/18 2018/19 2019/20 2020/21

£k £k £k £k

2,727 3,055 4,254 5,437

28

Sustainability and Transformation Fund

A national Sustainability and Transformation Fund (STF) is held by NHS England to support local health economies. The amount in this fund increases each year, and rises to £3.8bn nationally by 2020/21. We were notified in June that for 2020/21 our share of this Fund is £47m, and we have incorporated this in our modelling.

At the beginning of October local NHS providers were allocated a share of the Fund to support their financial positions – approximately £22m for both of the next two years. A further £4m has been requested to support the position of Frimley Health for the next two years.

We also know that an additional £1.1bn is available for ‘transformation’ in these years. A pro-rata share of this for use would be £13.5m, which would help support funding of the solutions we have described in our STP, including the ‘double-running’ costs. But to continue at pace, deliver financial balance, and realise the benefits for our local population we need more than this. We are therefore requesting a further £2.5m each year. Therefore the additional ask over announced funding is £20m (£4m + £13.5m + £2.5m)

Balancing each year of the plan

The graph shows the financial gap for the health system if we ‘do nothing’, with the cumulative impact of or savings, efficiencies and solutions.

The table to the right gives a high level view of progress towards achieving financial balance across the Frimley Health and Care System.

Annual Impact

Sectio

n Fo

ur

28 Finance & efficiency – overall impact of our plans Se

ction

Six

2017/18 2018/19 2019/20 2020/21

£m £m £m £m

Do nothing Health Gap -85.6 -128.4 -166.6 -187.1

Provider CIPS 24.5 49.6 74.0 97.4

Commissioning QIPPS 9.8 14.4 18.8 23.5

Specialist solutions 11.4 16.9 23.0 30.0

Transformational solutions (net) -0.3 4.7 12.2 18.4

Control Totals -23.2 -23.2 -7.2 -7.4

Other 22.0 24.2 16.1 0.0

Agreed STF funding 21.3 21.8 47.0

Requested STF funding 20.0 20.0 38.0

Health Position 0.0 0.0 8.2 21.8

Remaining Social Care Gap -8.3 -11.9 -13.7 -21.9

System Position -8.3 -11.9 -5.6 -0.1

29

Sectio

n Fo

ur

29 Finance & efficiency – summary to 2020/21 Se

ction

Six

2015/16 2016/17 2017/18 2018/19 2019/20 2020/21

Increase

from

2016/17

£m £m £m £m £m £m %

Secondary Care

- Acute 485 499 502 510 515 523 5.0%

- Mental Health 71 75 81 83 86 89 18.9%

- Community 58 56 62 62 64 67 20.5%

Continuing Care 63 67 71 76 81 87 31.3%

GP Prescribing 94 94 97 101 105 110 17.0%

Primary Care 104 112 120 124 129 136 21.4%

Running Costs 16 16 16 16 17 17 4.3%

Other CCG 15 16 34 36 36 37 138.3%

Specialist 170 180 182 190 199 209 16.4%

Social Care & Public Health 256 272 277 282 285 295 8.4%

Total 1,332 1,385 1,440 1,481 1,516 1,571 13.4%

Key financial messages

• Our current ways of working are not sufficient to bridge the financial gap, and our broader efficiencies leave a £85m gap.

• The increases in CCG funding only cover the costs of inflation, not the demographic impacts – so effectively we have to “meet tomorrow’s demand with today’s funding”

• Commissioners and providers planning collaboratively will bring the system into balance, and will avoid the unintended consequences of traditional planning and contracting arrangements (for example stranded costs).

• We are not planning for any significant change in physical acute capacity (beds) but existing capacity needs to be redesigned to be used much more productively.

• There is alignment between providers and commissioners on the size of the challenge.

• We have a plan which meets the published control totals for NHS Trusts and CCGs for 2017/18 and 2018/19, and delivers financial balance across the health and social care economy by 2020/21

• To deliver this we need additional Transformation Funding of £20m in 2017/18 and 2018/19

30

Communications and engagement Se

ction

Seven

Purpose: To support the launch and the delivery of the STP by combining and coordinating the tried and tested

communication and engagement channels right across our system. We will continue to build on the successful

engagement with and involvement of our workforce, lay members, elected members, PPI/PPE leads and

Healthwatch and wider engagement with the voluntary sector and public. We believe that better decisions are

made when the public and professionals work together.

Priorities:

• The STP Communications and Engagement Group is well established and has completed the groundwork of

mapping the existing engagement activity and channels across the system, developing standard messages,

templates and engagement logs.

• Our plan doesn’t include any issues that require public consultation so we are aiming for an early publication

and launch. We are completing plans for this which will include a series of launch events with a clear

description of what our STP offers the public. Case studies are being developed to support communication,

including learning from NHS England on key messages.

• We want to continue to learn from and adopt best practice in engagement and co-production developed by

the Vanguard, the Surrey Heath Alliance programme and the New Vision of Care initiative. All of these have

benefited from working closely across health and local authorities and building on the expertise that exists

within our local authority partners.

• Our priorities and initiatives reflect the priorities we have heard from our residents and patients through those

programmes and we hope to drive change through the local parts of the system through schemes they

already recognise and have helped to shape.

• Our plans include extending the Community Ambassadors programme, which has 80 active volunteers

involved in change programmes, supported by a dedicated post with the voluntary sector, induction and

training programmes. The Patient Involvement Assessment Framework and KPIs for engagement will also

help support delivery of the STP.

The Communications and Engagement Action Plan and STP Engagement Plan are included as appendices.

31

Appendices

1. Public facing narrative – draft

2. Communication and engagement action plan

3. STP engagement plan

4. STP/LDR workstreams

5. STP technology investment case

6. STP general practice at scale investment case

7. The ten big questions

8. System Partners

32

Appendix 1: Public facing narrative

• The Frimley health and social care system is performing well and most towns satisfaction with GP services is among the highest in England. However, Frimley want to do more.

• Over the next four years, Frimley will invest £69 million in frontline NHS and care services to improve wait times, treatment and home care for local people.

• An extra £7 million every year will mean people can get a GP appointment from 8am to 8pm Monday to Friday, that’s 420,000 more GP appointments across Frimley.

• At weekends, specialist and family doctors, community nurses, occupational therapists, physiotherapists, social workers, psychiatric nurses, psychiatrists and pharmacists will offer treatment at the 14 new ‘health hubs’ likely based in Farnham, Fleet, Farnborough, Aldershot, Yateley, Surrey Heath, Bracknell and Ascot, the Royal Borough of Windsor and Maidenhead, and Slough.

• An additional £11 million for mental health services means patients who need specialist care will no longer have to travel out of the area.

• This extra investment will also fund more community mental health nurses, seven days a week so people can get the right support when they need it.

• A new multi-million pound radiotherapy centre built on the Wexham Park Hospital site will reduce travel times for local cancer patients.

• Frimley will invest in its frontline staff, GPs will more time to see patients and increase the number of community nurses and pharmacists.

• By putting £30 million into technology, patients will only have to share their medical history, allergies and medication details once, regardless of whether they are in A&E or GP surgery.

• Patients will be able to access their medical record online, and for those with diabetes, heart or breathing problems, technology can monitor things like blood pressure remotely, alerting the doctor to any problems.

• Working with people to tackle preventable ill-health, including help for 18, 000 people to prevent diabetes, reduce alcohol related deaths by 20 per cent, and reducing surgical infections by 150 a year by encouraging people to give up smoking for three weeks before their operation.

• Across the area, £130 million will be invested to bring the NHS up-to-date, including replacing the old Heatherwood Hospital in Ascot with a purpose built new hospital for operations such as hip and knee replacement, upgrading the Emergency Department and maternity unit at Wexham Park Hospital.

• And for GPs, millions of pound of investment for new GP hubs and upgrading GP surgeries across all areas.

Frimley health and care system

33

Appendix 2. Communications and engagement action plan

Priority 1: Making a substantial step change to

improve wellbeing, increase prevention, self-

care and early detection.

AIM ACTIONS Lead Completion

date

RAG

Develop and implement a communications and engagement

event with all the leads from each of our stakeholders to

identify how to develop communications & engagement for the

STP across the system

Developed Communications network & planned TW & SW

Last mtg

22/09/16

Develop broader communications network across partner

organisations in the STP

TW. Ac &

SW

Held 6/10/16

Develop list of communications and engagement leads for

Frimley Health and Social Care STP

List agreed but following event on 6/10 further amendments made GR 22/09/16

List being reviewed and asking for formal sign up from organisations TW/SW 21/10/16

Communications across the system - We will reinforce the

connections and ensure consistent messages which will

provide clarity for staff, patients and the public.

TW agreed to send progress updates to Network

TW 04/10/16

Communication briefings developed to be shared across the system -

We will target messages at a local level through the relevant

organisation & jointly develop key messages that can be used in

all settings to describe and explain the purpose and vision of our

STP

SW 20/10/16

Develop network meeting and governance structure Meetings now planned monthly and agendas, action log and future

actions all noted

ALL

Map engagement activity across the footprint to support

the delivery plan, making clear linkages between STP and

local activity. We will build on successful and productive

engagement already carried out and will learn from, share

and replicate best practice.

Template for collating information designed and distributed. Needs to

be ready to help support our messaging and priorities prior to launch

SW/ALL 8/11/16

Develop comms and engagement plan for sharing our draft

ambitions through a pro-active public launch that tells the

story in simple, clear language, using local examples of

where changes have or are already taking place to build

confidence in the proposed changes and demonstrate the

real, local benefits for patients and staff.

Developing ideas for a video message that can be shared widely

Planning a launch event/series of events to launch the STP

Briefings as above

ALL Dec

The development of the Frimley Health & Care STP is supported by tried and tested co production and engagement

channels used to support transformation with the public, voluntary sector, faith groups, and users of our services . We

have liaised with our lay members, local authority elected members, PPI/PPE leads as well as local Healthwatch

representatives and are planning a wider stakeholder engagement workshop to capture the local voluntary sector

organisations. The STP has an established group who’s aim is to coordinate the communications providing a consistent

approach across the wider STP footprint.

34

.

Stakeholders Staff & Clinicians Patient / Public/ Voluntary

System Wide Leadership Group – April, June, Nov 2016 Surrey Heath Alliance Healthwatch briefings June/ Sept

System Leadership Reference Group - Fortnightly East Berkshire System Leaders Group PPI/PPE/Healthwatch meeting Oct 16

Frimley System Directors group – Weekly/ Fortnightly NE H& F Vanguard Leadership Group Wider Stakeholder event - Nov

Wellbeing Boards – ongoing

Overview & Scrutiny committees – ongoing

Lay members of Governing bodies Aug/ Sept

Priority Setting Workshops – May/ June

Away days x 2 with FHFT wider leadership team

GP Federations

LMC reps

Local patient and public engagement events

LA Authority Elected Members Reference Group - June/

Sept

Integrated Care Decision making hubs - Sept AGMs

Thames Valley Senate - July GP Transformation workshop - Sept Annual members meeting for Frimley

TV Urgent & Emergency Care - July Unwarranted Variation meetings & workshop – Sept/Oct

Royal Berkshire Fire & Rescue Service Aug/ Oct Mental Health Workshop – June/ Nov

LWAB -Oct Frimley Staff Council

STP wide Communications event - Oct AGM

Annual members meeting for Frimley

STP progress updates STP Progress Updates STP Progress Updates

As part of the STP planning process we have strived to involve clinicians across all the initiatives but there is still more to be done. As we enter the delivery phase our staff, stakeholders and local communities will be key to its success and ongoing dialogue is essential.

Appendix 3: Frimley Health & Care STP Engagement plan 30

35

Making a substantial step change to improve wellbeing, increase prevention, self-care and early detection.

STP/LDR Workstream AlignmentFrimley Health/Slough, Windsor, Ascot & Maidenhead; Bracknell & Ascot; Surrey Heath and North-East Hampshire and Farnham CCGs

· We are targeting a reduction in

obesity, smoking & alcohol for

people with mental health

conditions, learning disabilities,

and for young people & families

· We have prioritised identifying

people with hypertension and

diabetes earlier, & improving their

self care and management

· More people will be supported at

home and in their community using

digital information, the voluntary

sector and health and care

professional advice

· People will experience improved

reported wellbeing and health

confidence and reduced social

isolation

· We will achieve earlier diagnosis,

improved self-care and clinical

management of diabetes and

hypertension. This will enable

people to avoid developing related

complications, reducing their need

to use health and care services.

Outcomes/Benefits

STP Priority 1

Vanguard Delivery Group

New Vision of Care

Better Care Fund

Frimley LDR Progr Board

BE IM&T Committee

Key

Record Sharing Workstream

Patient Facing Technology/

Preventative Care Workstream

E-prescribing Workstream

LDR

Cap

abili

ties

Asset & Resource Optimisation

Remote & Assistive Technology

Decision Support

Record, Assessments & Plans

Transfers of Care

Orders & Results Management

Medicines management &

Optimisation


Patient Facing Technology Workstream

Referrals/Discharge Workstream

Children’s Sharing Workstream


Care Planning Workstream

Infrastructure Workstream

Whole Systems Intelligence Workstream

Prevention and Self Care

General Practice Transformation

Social Care Support Shared Care RecordSupport Workforce Integrated DecisionsInitiatives



LDR Workstreams




Our aim is to change the focus from managing ill health towards one of prevention, early detection and self care. Overall the

health of our population is good so our aim will be to focus on closing the health and wellbeing gap in our communities with

poorer health outcomes. We will give greater support for individuals to take responsibility for their own health and care. We

want staff in every part of our system to promote healthy messages to our population as part of the care we deliver every day.

Appendix 4: STP/ LDR workstreams

36

Action to improve long term condition outcomes including greater self management & proactive management across all providers for people with single long term conditions.

· Many more people understand and

take control of the management of their

long term condition

· Effective best practice pathways will be

in place across our system, supported

where necessary by the combined

expertise of the appropriate health and

care professionals

· There will be fewer people in our

system with multiple long term

conditions and co-morbidity

· Carers will be supported to enable the

person they are caring for to manage

their condition and to reduce the

emotional stress of being a carer

· People with long term conditions will

report that they have improved health,

more confidence, increased wellbeing

and that they feel supported

· There will be fewer crises and a

reduced use of urgent and emergency

services

· We will achieve greater integration in

the care provided by all of the sectors

in our system with reduced duplication,

including integrating physical and

mental health.

Outcomes/Benefits

STP Priority 2












LDR

Cap

abili

ties



Decision Support


Transfers of Care



Optimisation



Social Care Support Shared Care RecordSupport Workforce Integrated Decisions



New Vision of Care

Better Care Fund

Frimley LDR Prog’me Board

BE IM&T Committee

Key

LDR Workstreams

Initiatives


20% of our population has one long term condition, 9% have two and 10% have more than two. Our aim is to improve the

management of LTCs before they get to a stage where they are complex and multiple. We want to improve the care and

outcomes for people with these conditions and to avoid or delay them acquiring more. We know that there is a particular need

to make improvements for people with severe mental health, learning disability and acquired brain injury.


37

Frailty Management: Proactive management of frail patients with multiple complex physical & mental health long term conditions, reducing crises and prolonged hospital stays.

· People are involved in and

understand their care and feel

supported and in control

· A standardised evidence based

approach is used to risk stratify our

population and identify patients

with greater needs

· Effective multi-disciplinary teams

with joint decision making and

strong clinical leadership are

established

· People report improved health

status, confidence and wellbeing

among our complex and frail

patients

· There are fewer crises and

reduced use of urgent and

emergency services

· More people are supported to live

in their own home with fewer

permanent admissions to care

homes

· High levels of staff and team

satisfaction and more opportunities

for personal and role development.

Outcomes/Benefits

STP Priority 3




LDR

Cap

abili

ties



Decision Support


Transfers of Care



Optimisation

Evidence from the leading international integrated care systems shows that health and wellbeing are improved and costs

reduced when there is a systematic delivery of population risk stratification, multi-disciplinary assessment and care planning,

effective care coordination and care navigation and proactive care. We will use local, national and international best practice

to design and develop effective proactive care in all of the natural communities/ localities across our system.
















New Vision of Care

Better Care Fund


BE IM&T Committee

Key


LDR Workstreams



38

Redesigning urgent and emergency care, including integrated working and primary care models providing timely care in the most appropriate place

· The public experience a simplified system,

have easy access to effective advice on self-

treatment and care, and are directed to the

most appropriate service where they will be

seen quickly

· All patients are able to receive an urgent

general practice appointment on the day, 7

days a week

· A responsive integrated care decision

making team provides more assessments in

the community, supporting professionals to

manage patients with urgent care needs

· Patients who require emergency care from

acute and/or mental health specialists will be

quickly assessed and streamed into the

most appropriate management, with fewer

delays

· Patients receive supported discharge from

hospital into an appropriate community

environment, once the acute phase of their

care is over

· There is more timely care, with shorter waits

across the whole system

· We achieve improved flow through the

system including ambulance turnaround,

urgent advice and treatment from primary

and community services, social care, A&E,

within hospitals and after acute discharge

· People report improved outcomes and

improved experience of using urgent and

emergency care services.

Outcomes/Benefits

STP Priority 4

LDR

Cap

abili

ties



Decision Support


Transfers of Care



Optimisation

Priorities 1-3 aim to reduce avoidable ill health, care for people in their homes, avoid crises and reduce the need

for urgent and emergency care. For patients who still require urgent/emergency care, we will ensure that we

have an effective, easily navigated and joined up system. Care will be delivered as close to home as possible and

appropriate for both physical and mental health.












New Vision of Care

Better Care Fund


BE IM&T Committee

Key






LDR Workstreams



39

Reducing variation and health inequalities across pathways to improve outcomes and maximise value for citizens across the population, supported by evidence.

· Reduction in variation across five

areas: circulation, neurology, GU,

MSK & respiratory to realise 65%

of the target savings

· Appropriate repatriation of physical

and mental health work currently

sent to specialist centres across

the country

· A demonstrated improvement in

the way we give choice and

options to people to enable a

shared decision making process

· Clinicians have a clear discussion

with individuals about the risks and

benefits of specific interventions.

· Improved outcomes for patients

across physical & mental health

· Stronger patient involvement

through shared decision-making

· Reduced clinical variation

benchmarked against national and

cluster data.

Outcomes/Benefits

STP Priority 5











New Vision of Care

Better Care Fund


BE IM&T Committee

Key




LDR

Cap

abili

ties



Decision Support


Transfers of Care



Optimisation



LDR Workstreams


Our aim is to use Right Care methodology to achieve a significant reduction in variation for our patients across the Frimley footprint. We will

develop a culture of value & population-based decision making involving clinicians across primary and secondary care to deliver the reduction

in variation. We will achieve this by working in the following way:

· Ensure patients are able to make informed decisions about their treatment, and encourage aligned conversations about the risks and

benefits of interventions

· Ensure patients access both primary and secondary care, across physical & mental health, as a seamless single clinical system

· Develop a system wide approach to specialised commissioning, including primary, secondary, physical, mental health care

· Beginning a conversation with the local population and stakeholder groups about the need for evidence based medicine, and the

potential impact of this upon local services

· Ensuring that clinicians have a clear discussion with individuals about the risks and benefits of specific interventions


40

Appendix 5: STP Technology investment case

• Improved quality of care through decision support systems

• Enabling timely clinical decision making

• Reduction in duplicate/unnecessary tests

• Time saving/increased staff productivity/efficiency

• Reduction in adverse events

• Medicines optimisation

Paper free at point of care

• The technology initiatives can be broken down into three categories- Information sharing, patient facing technology and paper free at point of care.

• Projects are a mix of organisational specific and cross system

ROI

• Medicines optimisations- reduction in adverse drug reactions, waste, corrective treatment , misappropriation

• Reduction in attendances/admissions/re-admissions/delayed discharges/ambulance conveyances

• Reduction in length of stay in high cost beds

• Eliminate costs associated with maintaining legacy systems

• Eliminate paper by using electronic- systems for communication

• Reduce adverse events- through e-alerts- e.g. MRSA prevention, electronic observations.

• Staff reductions – fewer administrative requirements/agency staff

• In addition to the national priorities outlined above, there are local challenges and opportunities that need to be progressed in order to support the STP priorities.

• A substantial opportunity exists around information sharing projects that are underway across the STP footprint. All health and social care organisations are engaged in complex information sharing projects requiring strong cross organisational boards. In short, partners are used to working at a system level on complex IT projects. Consequently, Frimley STP is well placed for receiving funding to support these and other initiatives as the existing structure supports rapid mobilisation.

• A core challenge is ensuring all organisations are at the same level of digital maturity, in order that that whole system projects can fully deliver. Frimley Health has distinct challenges as they continue the work to merge legacy IT systems across three hospitals., following acquisition. This needs to progress at pace to ensure organisational benefits already identified. Without progress, the broader system benefits will not be achievable. Digital has been identified as a key enabler for all the STP priorities and will affect the realisation of the objectives listed.

Local Context

• Through the LDR process, it is now known that there are gaps in technology maturity that need to be closed in order to best support the STP.

• Nationally there are seven capabilities that need to be at levels close to 100% in order to deliver the national target of paper free at point of care. At a system level we are at:

• In addition, there are 10 Universal capabilities that need to be progressed, and organisational priorities that need to be supported by technology.

No Funding Provision

• This option is to continue funding the digital transformation agenda using

existing finite funding streams.

• We are proposing that this is not a viable option in light of the national

requirements around paper free at point of care, the wider digital

agenda across health and social care and the emphasis on information

sharing to improve patient care. Significant progress has been made on

information sharing across the system, but this has been at the detriment

of other initiatives to drive digital innovation.

Progress with limited national funding

• Partial funding of the overall request will enable the system to focus on

gaps in digital maturity to eventually enable some aspects of the

transformation required to support the STP.

• Priority will need to be given to the core building blocks in each

organisation to ensure that investment in cross organisation projects will

deliver the associated system benefits, but this approach risks enforcing

silo working and fragmented progress towards interoperability and

digitisation, ultimately impacting on the quality of care.

Progress with requested funding

• With the full amount of funding being requested, partners have an

opportunity to develop internal systems to progress their digital maturity

to ensure a solid equitable foundation.

• There will also be an opportunity to progress the significant

transformational projects which will fully support the STP priorities.

These include patient portals, remote and assistive technology and

whole system intelligence.

Options Information Sharing LDR- Current State

• Reduction in attendances at A&E, GP, & walk-in centre

• Ability to monitor multi co-morbidity patients from home, reducing returns to A&E

• Increased capacity in primary care- redirect patients to self care and alternative services e.g. pharmacy

• Remote triage higher number of patients

• Reduction in elective/outpatients

• Improve quality of care and outcomes through more consistent monitoring, improvement in long-term health and population outcomes and supports prevention agenda.

Patient facing Technology

Records, Assessments

& Plans

0.44

47%

Transfers of Care

0.48

57%

Orders & Results

Management

0.55

63%

Medicines

Management &

Optimisation0.3

29%

Decision Support

0.36

24%

Remote & Assistive

Technology

0.32

51%

Asset & Resource

Optimisation

0.42

69%

41

Paper free at point of care is the core deliverable as part of the LDR process and there are substantial benefits in achieving this. There are distinct challenges to achieving this within the Frimley STP with organisations at differing levels of digital maturity. Frimley Health have a substantial work programme to deliver as a result of the merger of three hospitals. This integration work is a fundamental enabler prior to being able to support transformation programmes linked to the whole digital ecosystem. There are also challenges for local authority partners and ensuring they have access to the N3 network and NHS numbers to support social care systems linking with health systems.

Projects to support paper free at point of care include projects to integrate systems across Frimley Health, Electronic Document Management System and E-referrals. In Primary Care, there are opportunities to look at stronger collaboration with care homes including a 24/7 health hub supported by video conferencing

The benefits of paper free at point of care include:

• Reduces administrative costs in paper handling. Distribution of

paper at Frimley Health is a substantial outlay using existing

systems.

• Benefits in releasing time to patient care as clinical staff

become used to paper free system across the system.

• Potential reduction of costly errors with system monitoring of

drug, interactions, blood types, inventories, etc.

Locally information sharing has been identified as key priority. Pre-dating LDR and STP, North East Hants and Farnham participated in the Hampshire Health Record, East Berkshire in Connected Care and Surrey Heath in the Surrey Interoperability programme. Moving forward, we are working towards alignment of these programmes within the STP footprint which is being supported with information sharing identified a key deliverable of the STP and LDR process.

The importance of this is reflected in the request for £13m across the health and social care system to support information sharing projects, including: Shared Care Record, referral management and e-prescribing.

Substantial benefits have been identified to support the investment. These include:

• The improved ability for decision making (staff and patients). Across the system this will result in substantial quantitative savings and qualitative improvements.

• Using data to support health and wellbeing and the better management of conditions to enable individuals to remain as independent as possible for as long as possible and support full recovery following physical and or mental illness regardless of social situation. Projects that support this have identified significant savings including a reduction in admissions, readmissions, delayed discharges, and length of stay.

• Enables better coordination of care ensuring that potential avoidable crisis are averted. These projects will lead to reduction in admissions/re-admissions and outpatient appointments

• Supports integrated team working by enabling the development of integrated care plans for individuals being managed by integrated teams. This supports better care management which will lead to a reduction in admissions and improvements in health outcomes.

• Supports prospective care planning

• Reduction in time looking for information= leading to an increase in clinical efficiency/productivity

• Reduces adverse events and improves clinical safety

• Supports transfers of care, delayed discharges as next of kin and care information (including care plans) will be available to care professionals resulting in a reduction in length of stay or transfers to care homes

Patient facing technology has the potential to provide the greatest

financial saving across health and social care. Substantial

transformation behavioural change (staff and patients) will need to

take place, but supporting individuals take greater control of their

care at a whole system level has enormous potential to reduce

pressure across the STP footprint.

Proposed projects to fully exploit the potential of patient facing

technology across the STP include a patient portal, telehealth

solutions including care companion, self care signposting,

read/write access to patient record and appointment reminder

technology.

Although evidence is not as strong for financial savings with patient

facing technology, there is a drive to deliver whole system change

involving patients.

The potential benefits of patient facing technology include:

• The ability for individuals to input data into their own record will

create a shared responsibility between people and health and

social care services. Increased ownership and monitoring in

this way had been shown to reduce A&E attendances,

outpatient appointments, walk-in centres, GP attendances and

delivered improved health outcomes and management of long

term conditions.

• Developing shared responsibility potentially increases

individual satisfaction (increased confidence and health/self

awareness) and staff levels of satisfaction (reducing vacancies

and need for agency staff), reduces system costs in terms of

non attendance, reducing waiting times and increased

utilisation of staff.

• Ensuring that care professionals have access to information

recorded by an individual prior to an initial consultation resulting

in efficiency savings and improved qualitative improvements

and higher quality of care.

• The ability of staff and patients to monitor health supports the

prevention agenda, safeguarding and wider population health

outcomes.

• Greater capacity for self care and uptake of alternative care

services e.g. pharmacy.

Patient Facing Technology Paper free at point of care Information sharing

Appendix 5: STP Technology – benefits breakdown

Notes

The above cash releasing benefits are dependent on whole system transformation initiatives as part of the STP delivering benefits.

There is a risk of double counting benefits at this early stage and work will be done to identify what return on investment can be directly attribute to the technology.

Recent reports (e.g. Wachter) note the cumulative affects of broad health IT as the whole organisation transforms from many initiatives. Full realisation does not occur until 7-10 years post implementation of major health IT projects.

42

Appendix 6: STP General practice at scale investment case

Frimley STP is able to go further, faster with the transformation of General Practice and delivery of the resulting benefits. This is because:

We have the foundations in place to deliver at scale and pace. Underpinned by good leadership and engagement, clear gap analysis, evidence within local systems and a compelling case for change.

Delivery will be based upon spread of good practice across the whole of the STP to give both stability and redesign of services with a reduction in variation between localities (Year 1)

We are identifying clinical leaders and managerial support to push at our traditional local boundaries (technology, business models with scale, patient empowerment and primary/ secondary care interface) – to give full delivery of FYFV and transformation and sustainability roadmap by 2010 (Year 2)

Going further faster

The following investment is required to support us to go further faster and accelerate early delivery of benefits:

1. Investment for the STP for all new workforce role mentioned in FYFV in year 1 across all localities (five CCGs) irrespective of whether already part of PMCF or GP Access Fund. Mental Health Therapists, clinical pharmacists, care navigators and medical assistants.

2. All localities(CCGs) across the STP to receive Funding to Improve Access to General Practice Services in Year 1 (2017/18) irrespective of whether already part of PMCF or GP Access Fund. £6 per head of STP population.

3. Early response to Estates and Technology Transformation Fund local bids (end Dec) so that estates support to transformation can be planned – a vital ingredient to our plans

4. Early release to system of funding for reception and clinical staff training and online consultation systems (full sight of tranche’s early so that full programme can be scheduled) to enable cohorts of training & increased pace

5. Pump priming money (non-recurrent) to enable full STP wide workforce assessment & development plan, Integrated Care Hubs across the STP to optimise out of hospital care & upskill other health and care professional to manage less complicated problems. (Support workload transformation)

Financial investment

Non-elective Admissions age > 65 from A&E

Rolling 12 months average/1000

Illustrative of what Surrey Heath have

achieved – investment circa £3M additional

(which includes community& mental health

investment)

Appendix 6: STP General practice at scale

System Wide Strengths: • Stable & experienced clinical

leadership across all areas • High levels of practice engagement • Commitment to GP at scale . GP

federations in place covering all the population

• Practices with strong training history/workforce innovation

• Population recognises role of general practice at heart of health and care system & local political support

• GP risen to challenge as leader of system change. Role recognised by wider system.

• Clinical & managerial partnership approach

• Strong clinical interface between secondary & primary care

System opportunities • Outcomes variable, inequalities &

scope for spread of good practice (access, LTC management, early identification, self care & prevention)

• Strong case for change - No locality sustainable in “do nothing scenario”

• History of pockets of innovation – can deliver at pace individually (see below)

• Variable investment: negating opportunities for scale

However some areas for improvement: • High levels of GP referrals • High and rising levels of emergency

admissions • Some areas lower quartile

performance

Local Context

• Eliminate variation between localities so collectively are the highest performing general practice system nationally

• Meeting all components of the GPFV before 2020 (March 2019)

• Investment delivers within 2 years STP wide: • Sustainable Clinical

Model • Workforce strategy and

clear sustainability plan • Business Model that

works for practices and health and care system

• Embedded network of innovation & shared learning for general practice

• Urgent care models and resilient system that draws on GP information as part of a “live” system of demand and capacity management

• Fully integrated use of technology throughout the general practice care pathway from appointment booking to self management

Future State Evidence of

Successful Initiatives

Direct Access Physio in General Practice

• Booked by Receptionist • 15 minute appointments • Extended scope

practitioner • Referral for exercise, on

going physio, injection, investigation, referral to secondary care or GP.

• 20% reduction in physio and secondary care referrals

• 95% FFT

8 to 8 Working (M-F)

• Rapid implementation from concept to delivery

• Data sharing agreement with access to EMIS web

• Larger practices operating solo, smaller practices operating across 2 or 3 sites

• Above national average patient satisfaction (92%)

• Reduced NELs for >65yrs

Infrastructure investment enabled Phase 1: Establishment of Integrated Care Decision Making Hub with GP as core member Phase 2 GP Urgent care hub (from early Nov) • Same day appts access

across 5 GP populations • Releasing time to offer

longer appointments for patients with LTC this initiative improves both urgent appointments and personalised LTC management

Proactive Care for Complex Needs • Risk stratification identifying

patients who benefits from more intensive support through a period of regular appts with GP

• 20 mins appts every 3 weeks • Evidence of reduced hospital

admissions & A&E attendances

Needs based referral • Single point of referral for

integrated community services using a “needs based” approach

• Saves GP time • Optimises use of integrated

community MDT • Improved access to social and

voluntary sector for general practice

• No door is wrong door approach for professional

Workforce Access Infrastructure

Complex Needs Workload

STP Fund

• Early investment

• No phasing • Across all

localities • Scale and

pace of delivery

Appendix 7 The ten ‘big questions’ The table below gives a brief summary of how our STP and local plans will enable us to address the ten NHSE ‘must dos’

Our priorities 10 big questions addressed?

1. Making a substantial step change to improve wellbeing, increase prevention, self-care and early detection.

• Enrolling people in the Diabetes Prevention Programme • Do more to tackle smoking, alcohol & physical inactivity • Improve the health of NHS employees and reduce sickness rates • A step change in patient activation and self-care

2. Significant action to improve long term condition pathways including greater self management and proactive management across all providers for people with single Long Term Conditions.

• A reduction in emergency admissions and inpatient bed day rates (via prevention and improved care pathways for LTC)

• A step change in patient activation and self-care

3. Frailty management: providing proactive management of frail complex patients (not just elderly), having multiple complex physical and mental health long term conditions, reducing crises and prolonged hospital stays and delaying reliance on bed based care.

• Health and social care integration with a reduction in DTOC • A reduction in emergency admission and IP bed-day rates

• Integrated multi-disciplinary teams to underpin new care models

4. Redesigning urgent and emergency care, including integrated working and primary care models providing timely care in the most appropriate

• Integrated 111/OOH services with a single point of contact • A simplified UEC system, with fewer, less confusing points of entry • Improved A&E and ambulance waits and RTT

5. Reducing variation and health inequalities across pathways to improve outcomes and maximise value for citizens across the population, supported by evidence (using Right Care methodology)

• Achieving a significant reduction in avoidable deaths

• Credible plans for moderating activity growth

Key initiatives

i. Ensure people can take responsibility for own health & wellbeing

ii. Primary care transformation

iii. Transform the social care support market

iv. Design a support workforce that is fit for purpose, cross system

v. Implement a shared care record

vi. Develop integrated care decision making hubs

• Support primary care redesign, workload management, improved access, more sharing working across practices and improving the resilience of primary care

• Expansion of integrated personal health budgets and choice

• Developing, retraining and retaining a workforce w/ the right skills

• Full interoperability by 2020 and paper free at point of use

• A reduction in IP admissions to hospital (+care home admissions)

Areas to be covered in a broader range of footprints To be covered in local plans

• Mental health specialist services and tertiary services • Procurement across different footprints for example 111 tendering • Digital roadmap • Learning Disabilities and Transforming Care Partnership • Cancer strategy • Safeguarding Adults and Children • Specialist acute services • Emergency care networks

• Ensuring most providers are rated outstanding or good • Full roll out of seven day hospital services clinical standards • Reducing agency spend • Improved anti-microbial prescribing and resistance rates

4

1

4

2

9

7

2

4

5

10

9

3

4

44

6

2

8

8

6

Appendix 8 System partners

NHS Commissioners • Bracknell and Ascot CCG

• North East Hampshire and Farnham CCG

• Slough CCG

• Surrey Heath CCG

• Windsor Ascot and Maidenhead CCG

Acute care provider • Frimley Health NHSFT

Mental health and community providers • Berkshire Healthcare NHSFT

• Southern Health NHSFT

• Surrey and Borders NHSFT

• Sussex Partnership NHSFT

• Virgin Care

GP Federations • Bracknell Federation

• Federation of WAM practices

• Salus GP Federation (North East Hampshire and Farnham)

• Slough GP Federation

• The Surrey Heath community providers

GP out of hours providers

• East Berkshire Primary Care

• North Hampshire Urgent Care

Ambulance Trusts

• South Central Ambulance Service NHS FT

• South East Coast Ambulance NHS FT

County Councils (including Public Health)

• Hampshire

• Surrey

Unitary Authorities

• Bracknell Forest Council

• Royal Borough of Windsor and Maidenhead

• Slough Borough Council

District and Borough Councils

• Guildford Borough Council

• Hart District Council

• Rushmoor Borough Council

• Surrey Heath Borough Council

• Waverley Borough Council

45

Frimley Health and Care System Sustainability and ......ambition to transform the ‘social care...

Documents

Transcript of Frimley Health and Care System Sustainability and ......ambition to transform the ‘social care...